R-5728 f APPLICATION FOR CITY OF CUPERTINO NUMB R R- 5728
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408)777-9228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
9 -/ / RESIDENTIAL I COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME P C _.b roof assembly is required.
NO ❑ Initial I.C.B.O.k
ADDRESS 5ps- �� // O 1 EXISTING ROOF COVERING
PHONE / NUMBER OF EXISTING COVERINGS
CONTRACTO
NAME TO BE REMOVED TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
CITY 8 ZIP
�7 EXISTING
PHONE YIJ� fr9 `/3�3 BUILT-UP ROOF ❑
L22
ICENSE /, ❑ ��j
NUMB
ER 7 ASPHALT SHINGLES
LIC NSED CONTRACTORS DECLARATION
I hereby attire that I am licensed under PrOvieions of Chapter 9(commencing with Section WOOD SHAKES
41
7000)of Division 3 of the Business and Professions Code,and my license Is in full force and
effect.
WOOD SHINGLES ❑
License Class L- 3� LIc.Number
Data -
2117 Contrr OTHER(SPECIFY)
❑
actor
OWNER-BUILDER DECLARATION ZPROPOSED k7 A D
I hereby affirm that I em exempt from the Contractor's License Law for the to owing reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,alter,improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF � �
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions s,0"
of the Contractor's License Lew(Chapter B(commencing with Section 7000)of Division 3 of the MS N
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLE ❑
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of not more than five hundred dollars($500).): GI I Y Ur V V-cl 0
❑I,es owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes-
slone Code:The Contractors License Law tloes not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,provided that ❑
such Improvements are not Intended or offered for sale.If,however,the building or Improvement //�
/ �/' �
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) Pt/Xz e. /
not build Or Improve for purpose of sale.).
0I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(sec.7044,Business and Professions Code:The Contractors License taw does not PROVIDE I.C.B.O.REPORT NO,
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contrectoge)licensed pursuant to the Contractor's License Lew, PROVIDE MFGR. INSTALLATION SPECS.
C]I am exempt under Sec. ,B 8 P.C.for this reason
Owner Dere
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
I]I have and will maintain a Certificate 01 Consent to sell-Insure for Worker's Compensation, /�'� BuildiJD�ATE
as provided for by Section 3700 of the Labor Code,for the petcrmance of the work for which this (
permit Is issued. Seism
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 Of
the Labor Code,for the performance of the wor for which this permit Is issued,My Workers Compensa' Insuren carrier@p -�Ilcy num rare: /i� ' pTotalterrier �e- /�`7 POIIcyNo./__(_4 9'249 PERMIT AUTHORIZATION CER IFICATE OF EXEMPTION FROM WORKERb�'COMPENSATION INSURANCE N.C.
(This section need not be completed II the permit Is for one hundred dollars($100)or less.)
I certify that In the performance of the work for which this permit is Issued,I shell not employ
any person In any manner so as to become subject to the Workers'Compens Ion we r all- All r s s all be inspected prior to any roofing material being
lornie. r installed. If a roof is installed without first obtaining an
Date Applicant ' -inspection,I agree to remove all new materials for inspection.
subject Ito the
Workers'Compeiaftns tion prkl felons of theflcate of Laborr Code,Exemption,
must fo thwlld comply Applicant understands and will comply with all non point
with such provisions or this permit shell b seemed revoked. source regulations. -
I certify that I have reed this application and state that the above Information is correct,I agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof coverings to be class" "or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, Y / -77
judgments,costa and expenses which may In any way accrue against mid City in consequence
of the granting of this permit. I A E APPLICAN DATE
PRE-INSPECTION: PLYWOOD: el IN-PROD SS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY