R-5377 APPLICATION FOR CITY OF CUPERTINO
NU BERPE5377
INSPECTION DIVISION PERMIT EXPIRATION
• REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
• BUILDING ADDRESS
(J tl tiff 0 li(//1/ p 2 RESIDENTIAL COMMERCIAL OTHER
Ow ER'S S1 / HAZARDOUS FIRE AREA
YES ❑ If yes—I u
NAME D (/� !A� /y understand that a Class A
roof assembly is required.
NO Initial I.C.B.O.If-
ADDRESS—
fADDRESS r Nl,� EXISTING ROOF COVERING
PHONE Q 3 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME �.` PLO ll O /Lor96 iii//" 70 BE REMOVED �f TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
CITY BZIP /2 12,,C' 771 w //✓. ZOS
EXISTING
PHONE 7 YC" �!� 7 S'- BUILT-UP ROOFLICENSE - ❑
NUMBER - -7 ASPHALTSHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license is in full force and
offset. O WOOD SHINGLES ❑
License Class �— 3 / Lic.Number 3 1 /�
/B//3�t� y _ OTHER(SPECIFY) ClDate Contractor r r
OWNER BUILDER DECLARATION PROPOSED
hereby affirm that am exempt fromthe Contractors License Law for the following reason.
(Sac. S,Business and Professionss Code: Any city or county which requires a permit to
construct,
alter,Improve,demolish,or repair eny structure,prior to Its Issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to Ills a signed statement that he IslicensedSectio pursuant to the provisions
of the Contractor's License Lew(Chapter 9(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 ASPHALT SHINGLES ❑
• axemppen.Any ltyofolt ion more than ionfive h031.5 undred any applicant fora permit subjects the applicant to
e civil penalty of not more men live hundred employees
dollars(h wag): WOOD SHAKES
❑I,as owner of the property,or to employees with wages as c.7 sole compensation,will do ❑
the work,and the structure is not intended ores nottl for sale(Sea owner
of Business and Proles-
donsCode:The Contractor's LicenceLewdoesnotapply rthrotoansonarofproperty who builds or WOOD SHINGLES ❑
Improves thereon,and'who tloes such work himself or through his own employees,provided that
such improvements are not intended or offered for sale.If,ill however,the en of pr or proving
T
Is sold not
or
year of for purpose
sal .owner-0ullderwlll have the burden of provinglost he did OTHER(SPECIFY) r 1`e
' not build or improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Law 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 contractor(s)licensed pursuant to the Contractor's License Law, PROVIDE MFGfl.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICATIORFEAT VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION Y n
I hereby affirm under penalty of perjury one of the following declaration: �^yr
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, ®cr j BUIIdIn� I
as provided for by Section 3700 of the Labor Code,for the perlormance of the work for which this
permit is issued. ClSeismic l
Rn have and will maintain Workers Compensation Insurance,as required by Section 3700 of /y �N
the Labor Code,for the performance of the work for which this permit is Issued.My Worker's (�
Compensation Insurance carrier ani number are: t/YCN�r r- q Total
Carrier S `T� Policy No.�r�7— ��s3 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0 19A xa?
(This section need not be completed if the permit is for one hundred dollars S1 00)or less.)
I certify that In the performance of the work for which this permit Is Issued,I shall not employ
any person in any manner so as to become subject to the Workers'Compensation Laws of Cali. All roofs shall be inspected prior to any ro fing materia b ing
forma. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP P Y P
with such provisions or this permit shi lCbe 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 state 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-
spection purposes. �••�
(Wo)agree to ands, Indemnify and keep harmless the City ai Cupertino against liabilities, `��
judgments,costa and expenses which may In only way accrue against said City in consequence
of the granting of lois Parma. SS GNAT— U�APPLICANT 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY