R 5202 PERMIT R_ 5202
.
APPLICATION FOR CITY OF CUPERTINO NUMBER
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 I C�l ff
RESIDENTIAL COMMERCIAL OTHER
OWNER'S pHAZARDOUS FIRE AREA
U l 5�i Cu CE—(�(,� [�(S� YES ❑ If yes s understand that a Class A
NAME
roof assembly is required. ^�
NO Initial-cp LGB.O.#_20
ADDRESS
22331 I�1 D (,V ST2f'C7 EXISTING ROOF COVERING PHONE Z`7'/
S -2 7 7 NUMBER OF EXISTING COVERINGS '
CONTRACTOR'S, I -
NAME Y vL !4'-t IM nu Q_Vr)1 C!4-f1. . , TO BE REMOVED I TO BE RETAINED
ADDRESS 'y TYPE OF ROOF COVERING
CITY B ZIP EXISTING
PHONE _ U BUILT-UP ROOFLICENSE
❑
NUMBER 5 9 ASPHALT SHINGLES
1:1LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES r ❑ /
7000)of Division 3 of the Business and Professions Cotle,and my license Is In full force and ®� L
effect. Q
Lr 3Q X526,; � C WOOD SHINGL� ❑
License Class Lia Number , ����rr�� � 2
Date 1 L �4 7 ContractormL-u I MUM 206E CH-RE OTHER(SPEQII�JJ� � ❑ ?/
OWNERBUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor'.License Law for the following reason. PROPOSED
(See.7031,5,Business and Professions Code: Any city or county which requires a permit to
construct,all er,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 Contractors License Lew(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 ASPHALT SHINGLES ❑
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500).): WOOD SHAKES. ❑I,as owner of the property,or my employees with wages as their sole compensation,will do ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes-
sions Code;The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES 1
Improves thereon,and who does such work himself or through his own employees,provided that ❑
such Improvements are not intended or offered for sale.If,however,the building or Improvement �c�, ,` ��
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) Nl 11J
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
Me project(Sec.7044,Business and Profeselons Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO. 2UOi3
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractors License Law, PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B$P.C.for this reason
Owner oats
WORKERS COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FE
I hereby affirm under penalty of perjury one of the following declaration: 1110111
❑I have and will malnul a Certificate of Consent to 98114nsure for Workers Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this ` /' (/� �/^^ �Y
permit lave and I�/3/C700 oftl�, I "' I� IW `-'lJ SBIS
ev—
❑ have and will themaipert Worker's Compensation the work
Insurance,ere required Is I su Section Worker's l 1
rA
the Labor Cotler for the performance of the work lar which Ihla permit la resod.My Worker's
Compensation Insurance carrier and Polley number are: Total
Carrier P0 N D Policy Q-zq '9 ics mG 9" PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N,C.] a R�
(This section need not be completed It the permit Is for one hundred dollars($100)or lees.) i s�
I certity 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'Componsanon Laws of Call. All roofs shall be inspected prior to any roofing material being
lornle. installed. If a roof is installed without first obtaining an
Date Applicant inspection, I agree to remove all new materials for inspection.
cubed too the Workers'Cf,after Compensation provisionis ofethelcate of Labor Code,Exemption,
mustuforthwlitthbecome
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 I have reed this application and state that the above Information Is correct.I agree
to comply with all city and aunty ordinances and state laws relating 10 bulltling 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.
apache)purposes. 0 q /
(We)agree to.eve,expenses
and keep harmless the e a of Cupertino against liabilities,ence l SO
of the gran costa and expenses which may In any way accrue epelnet veld Clty In consequence
• of the granting of this permit. SIGNATU 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
OFFICE COPY