R 5120 PERMIT R_ 5120
APPLICATION FOR CITY OF CUPERTINO NUMBER.
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
• WITHIN 1 DAYS PERMIT ISSUANCE O
7 F DAYS FROM LASS T CALLED INSPECTION..
BUILDING ADDRESS
C;z 2 3 z/ �NRESIDENTIAL Af!!�- COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes-I understand that a Class A
NAME • A419OCroof assembly is required.
/ L NO Initial I.C.B.O.q
ADDRESS r� EXISTING ROOF COVERING
PHONE O NUMBER OF EXISTING COVERINGS
CONTRAC R'S
NAME
/,4��,( S TO BE REMOVED TO BE RETAINED -
• rG//// — �� ryLw (r/.sh /�iwi
ADDRESS _ TYPE OF ROOF COVERING
CITY 8 ZIP 3 Seh^. J/JG n /'�" 5.a �?s—/z4 EXISTING
PHONE— �1�— Cf?2 2� BUILT-UP ROOFLICENSE
❑ �\
NUMBER L2D C ❑ ��
0 3/
LICENSEONTRACTORS DECLARATION ASPHALT SHINGLES
hereby affirm that I em licensed under Professions
eons of Chapter a(commencing with Section WOOD SHAKES 9�
7000)of Division 3 0l the Business end Proleeslone Cotle,end rtry license le In lull force antl
effect. ..�7�, WOOD SHINGLES E]/
License Ct... ` 51%
% Lie.Number ;2 0
Date $��d�LL(< Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION"- PROPOSED
I hereby affirm that I am exempt from the Contractors 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's License Law(Chapter a(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 ❑
exemption.Any violation of Secll°n 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than live hundred dollars($500).):
C]1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profes.
alone Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work hlmsolf or through his own employees,provided that ❑ &v
such Improvements aro not intended or offered for leer.ill however,the en Of pr or Improvement
Is not ld bull thinor
prove for purpose
sthe ownerbulldrr will have the burden of proving Net he tlld OTHER(SPECIFY)
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
[II am exempt under Sec. ,B$P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
[ I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation,
as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which this 6o dm Buildin
permit Ind. '��G 21 1996 1y 1, 1 Seismic
and will the perftain Worker's C the wok for Insurance,as perequired by Sectiod.Myn 3700 s /
the Dor Code,for the pedormand of the work for which this permit is Issued.My Workers
Compensation insurance sorrier and Policy number are: ��'1 j' (;I. Lr r Total
Carrier D'� l /_(L,/ Policy No. J tr21'4 PERMITAUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORK E S'
COMPENSATION INSURANCE N.C.I]
(This section need not be completed If the permit is for one hundred dollars($100)or lase.)
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'Compensation Laws of Call- All roofs shall-be inspected prior to any roofing materia being
fornia. ^—� installed. It a roof is installed without first obtaining an
Data 4 Applicant f/, .. inspection,I agree to remove all new materials for inspection.
NOTIC Tosubject tote Workers'Compeinsation provision�ehelcate of Laborr Code,y °'you should bosomy Applicant understands and will comply with all non point
you moat forthwith comply source regulations. p y
-
with such provisions or this permit shell be tleemetl revoked.
I certify that I have read this application and elate that the above Information Is correct.)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. c
spection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, — Oc
jutlgmenta,costa and expenses which may In any way accrue against said City In consequence
of the granting of this permit. SIGRATURE OF 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
x OFFICE COPY