R 5797•
PERMIT R- 5797
APPLICATION•FOR clrY of cuPERrINo NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOFPERMIT (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
/(/7
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
L�
YES El 11yes — I understand that a Class A
NAME
��1
NO roof assembly is required
tial I.C.B.O. tt
5�
OZAb
EXISTING ROOF COVERING
ADDRESS—/ !`,d�/17d.2E C-1' ;
/
PHONE •
NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
i /+
NAME C..�
TO BE REMOVED TO BE RETAINED
ADDRESS
TYPE OF ROOF COVERING
CITY&ZIP � /L%G.(��/!iJ
EXISTING
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PHONE �r%G3•%
❑ -
BUILT-UP ROOFLICENSE
NUMBER 6
ASPHALT SHINGLES ❑
LICENSED CO TRACTORSDECLARATION
I hereby affirm that I am licensed under provisions of Chapter B (commencing with Section
WOOD SHAKES
7000) of Division 3 0l the Business and Professions Code, and my license Is In lull force and
/
effect. %7 6
���
WOOD SHINGLES ❑
License Class 5� Llc. Number / /
Date s --%g'-_ contractor
'
OTHER (SPECIFY) ❑
OWNER-BIILDERD R
I hereby affirm that I am exempt from the Contractors LI Law for the following reason.
(Sac. 7031.5, Business and Professions Code: Any city ounry, which requires a permit to
PROPOSED
construct, alter, Improve, demolish, or repair any structure, nor to its issuance, also requires the
BUILT-UP ROOF
applicant for such to lila a signed statement that he Is licensed
permit pursuant to the provisions
of the Contractor's License Law (Chapter g (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 SHINGLE, x
exemption. Any violation 0l Section 7031.5 by any applicant for a permit subjects the applicant to
Nt y1
to
a civil penalty of not more than five hundred dollars ($500).):
01, as owner of the property, or my employees with wages as their sola compensation, will do
the work, the Is intended
`�y►►PP \
SHAKES 1, VV TG
V
and structure not or offered for sale (Sec. 7044, Business and Profes.
Bions Code: The Contractor's License Law does not apply to an owner of property who builds or
f.
WOOD SHINGLED
Improves thereon, and who does such work himself or through his own employees, provided that
❑
such Improvements ere not intended or offered for sale. If, however, the building or Improvement
Is sold within one year of completion, the owner-buildar 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 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.
❑ I am exempt under Sec. ,B & P. C. for this reason
PROVIDE MFG R. INSTALLATION SPECS.
Owner Date
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION
PERMIT FEE
1 hereby affirm under penalty of perjury one of the following declaration:
I] I have and will maintain a Certificate of Consent io Bell -insure for Worker's Compensation,
for by Section
permit
BUIlding
3700 of the Labor Code, for the performance of the work for which this
permit le Issued,
Is Is
` is �/ I
l i(/�C�//l([
$915mIC
and
❑ 1 neve entl will fain Workers C enation Insurance, as required by Section 3700 of
the Leber Code, pa ,mance the work for which this permit Is Issued. My Workers
Compensation I sur ce mer an liey number are:�j
j
�7 � O
�/
Total 1
Carrier Policy No L'12 �J7
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXE TION FROM WORKERS'
COMPENSATI NINSURANCE N.C.[
(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 shall not employ
All roofs shall be in pec ed prior to any r ofin mat i ial
any person in any manner so as to become subject to the Workers' Compeneation Laws of Cali-
far°Ia' (�/
installed. If a roof is installed without first ob fining an
Date —� Applicant
Inspection, I agree to remove all new materials for inspection.
NOTICL�TO A PLICANT: If, after making this Certlll a of Exemption, you should become
subject to the Workers' Compensation provisions of th KeCoda, you must forthwith comply
A li t understands and will Comply with all non point
pp P Y P
with such provisions or This permit ehalQbe deemed r eked.
SO Ce gulations.
I certify that l have read this application and state at the above information is correct.) agree
to comply with all city and county ordinances and state Tawe relating to building construction, antlII
r00 OVerin s to be class "C" battle.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
'
spection purposes.
(We) agree to save, indemnity and keep harmless the City of Cupertino against liabilities,
judgments, costs and expenses which may In any way accrue against said Cly In consequence
of the granting of this permit.
UR O PLC NT AT
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