R 5800 APPLICATION FOR city of cuPERTINo
NUMBIER R" 5800
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3226 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
1BO DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS T
G 7
5- %��C.a Ave, RESIDENTIAL COMMERCIAL OTHER
• OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME G�L7 _ .V 4' _ roof assembly is required.
NO -A Initial I.C.B.O.It
ADDRESS— c)4 ZO C)A,,, r G 7�c v Q EXISTING ROOF COVERING,
PHONE
GJ (s ( 2 ZO CONTC�,OS NUMBER OF EXISTING COVERINGS
NAME CT05'S
NAME
G! �'+ L, d O �—r 1. !� • TO BE REMOVED 611TO BE RETAINED
ADDRESS ����� J /� -/ T TYPE OF ROOF COVERING
CITY&ZIP EXISTING
PHONE BUILT-UP ROOF ❑
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 111 licensed under provisions of Chapter B(commenting with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license la in full force entl
affect WOOD SHINGLES ❑
License Claes Lie.Number
Data Contractor
OTHER (SPECIFY)
NER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following 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
of the Contractor.License Lew(Chapter a(commencing with Section 7000)of Division 3 01 the
• Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031,5 by any applicant for a permit subjects the applicant to 777
a civil penalty of not more than five hundred tloliere($500).):
[3 1,as 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(Seo.7044,Business and Profes.
• alone Code;The Contractor.License Law does 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.II,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) ❑
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 Contractor's License Lew 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 Lew, PROVIDE MFGR.INSTALLATION $PEC$.
E]I am exempt under Sec. ,B&P.C.for this reason
Owner oats APPLICATIONID VALUATION R I FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, O 1D
as provided for by Section 3700 of the Labor Code,for the performance of the Work for which this tyn p�7 2 47 U11 ding
permit Is Issued. YV1Fo 1 /w/ 6 ISth C
t ❑I have and will maintain Workers f the work
for Insurance,as required by d.My Worker's
of (� (�(,�
the Labor Code,for me performance and of the work for which this permit I.issued.My Worker's C) uj: I,Uf r t Oso
Compensate Ina rAAce carrier and Policy number are: ��l � V IY Tot
i
Carrier � POIlcynlFT ��• / PERMIT AUTHORIZATIO DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.p
(This section need not be completed If the permit Is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this permit Is Issued,I shall not employ
any person In any manner so as to become subject to the Workars'Compensation Laws of Cali. All roofs shall be ins ect d prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
subect NOTICE1.the orkers'Compensation provisionis ofthelcate of Laborr Code,Exemption.
must forthwlithbecome comply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. Source regulations.
I certify that l have reed this application and state that the above information Is correct.I agree
tocomplywith all city and county ordinances and terulaws hrelating bovtobuildingconstruction,r in. fcoy$(jp tO SS" "Or better.
hereby comply
wth authorize city and county of this city to enter upon the above-mentioned properly for in. /v/
spectlon purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
judgments,osts and expenses which may In any way accrue against said City In consequence
•
at the%ranting at this permit. SIGNA FAPPLICANT 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 -