R 5777OFFICE COPY
APPLICATION FOR CITY OF CUPERTINO NUMBER R— 5777
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
• WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
I BUILOOInINGADDDRRESS
RESIDENTIAL_ COMMERCIAL OTHER
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OWNER'S Y�
HAZARDOUS FIRE AREA
VES [:1_ It I that eClass A -
NAME /�G77t !A///GC-C� 11r�J
stand
roof assembly
N required
NO .
❑ Initial I.C. B.O. #
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EXISTING ROOF COVERING
ADDRESS
1
PHONE d�J
NUMBER OF EXISTING COVERINGS
/ I
CONTR R'S
NAME
TOBE REMOVED TO BE RETAINED
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TYPE OF ROOF COVERING
ADORES
�3a
CITY 8," R
EXISTING
l
5�q3 -6 3 73
PHON4�j
BUILT-UP ROOF ❑ .
LICENSE 4�
7QONUMBER
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter B (commencing with section
WOOD SHAKES
7000) of Division 3 of the Business and Professions Code, and my license Is In full force end
enact
C � O
WOOD SHINGLES ❑
Cleanse Cis Lid. Number
qsa
/j:r/
OTHER (SPECIFY) ❑
Date 7 / Contractor
I hereby affirm that I em exempt from hI eContractor's License Law for the following reason.
PROPOSED
(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 El 4/04/-1
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Law (Chapter B (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he Is exempt therefrom and the basis for the alleged
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ASPHALT SHINGLES 0
exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
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a civil penalty of not more than live hundred dollars ($500).):
C] 1, as owner of the property, or my employee& 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 Profea-
&lona Code: The Contractoes License Law does not apply to an owner of property who builds or
Improves
WOOD SHINGLES ❑
thereon, and who does such work himself or through his own employees, provided that
such Improvements are not Intended or offered for gale. If, however, the building or Improvement
ISO Id within one yearol n, the owner -builder will have the burden of proving that he did
OTHER (SPECIFY) ❑
not build or Improve for oee o
❑I, ee awnerol tfy,em sly conir eetl conlregore to construct
the project (sec. 704as a Ione C d :The tr dors License Law does not
PROVIDE I.C.B.O. REPORT NO.
applytoan owner of orhobulldsar roves son, to contracts for such project
with econtrector(e)iursuant to the Contractors LIC W.
Dianne xempt u,B S P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
owner Date
WORKER'SCOMPENSATIOND ATION
APPLICATION DATE
VALUATION
PERMIT FEE
I hereby affirm u 91ty of perjury one of the lotto clarellon:
❑ have and will I Consent to sell re for Worker's Compensation,
for by Section 3700
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Building2-7
as provided o do ante of the work for which this
Permit la Is9oBtl,
51? 1,
/ / /0
7 Q�OS
Seismic Po
have end will maintain Worker's Compeneetlon Insurance, ea required by section 3]00 0l
/
the bor Cotle, for the pedormanca of the work for which this permit la leauad. My Workefa
Compengetlon Insu Policy
Total 12�
ce carrier entl number ere:
PERMIT AUTHORIZATION
DATE
Centel
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE IN CC]
(This section need not be completed If the permit Is for one hundred dollars (S1 00) or Idea.)
I that In
i 4:;'
V—A1
certify the performance of the work for which this permit Is Issued, I Shall not employ
any person In any mann eo ee to become subject to th rkare• campensation Laws of call.
All roofs shall be inspected prior to any roofing material being
romla'
installed. If a roof is installed without first obtaining an
Date Applicant ainspection,
I agree to remove all new materials for inspection.
U NOTICE TO AP LICANT: If, after making this Cer��118 ate of Exemption, you should become
SUto the Workers' Compensation provislona of X Labor Code, you must forthwith comply
A licant understands and will comply with all non Dint
PP p y p
with such provisions or this permit ehalgbe deemed revoked.
Source regulations.
I certify that I have read this application and state that the above Information is correct. I agree
to comply with all city and county ordinances and slate laws relating to building construction, and
All roof coverings to be class "C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
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eppurposes.
(We) to save,
(We) and keep harmless
ae the City of Cupertino liabilities,
� �� ` / f� J
against
judgments,co expenses w
of the gran costa and expenses which may In any way accrue against said City In consequence
of granting of into permit.
♦(`--�
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SIGNATURE ZF APPLICANT N a DATE
PRE -INSPECTION:' -
PLYWOOD: IN -PROGRESS:
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