R 5236 PERMIT R_ 5 2 3 6
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-.3228 PERMIT EXPIRES IF WORK is Nor STARTED
WITHIN 1e0 DAYS OF PERMIT ISSUANCE OR
A 01=C WI180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
a 0 15 "1 �, o� aDa o I,Ja.•1
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
� �/�y� YES ❑ If yes—I understand that a Class A
NAME '�`� of assembly is required.
NO Initial I.C.B.O.a
ADDRESS . / EXISTING ROOF COVERING
PHONE 5 :)•--0 9 97 NUMBER OF EXISTING COVERINGS
CONTRACTO
NAME
TO BE REMOVED TO BE RETAINED
QUA/ G', -
ADDRESS F ROOF COVERING
CITVBZIP '
EXISTING
PHONE BUILT-UP ROOF
LICENSE
NUMBER TR ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION A I)W
hereby affirm that em licensedantler provisions of Chapter (commencing with Section WOOD SHAKES Ir
m
7000)of Division 3 0l the Business
and Professions Code,and myy force
license Is In full force entl
effect. n nc
License Class C Llc,Number 73,(V WOOD SHINGLES M7' 31�JV
/U / OTHER(SPECIFY) Uhl ❑l b
Date Contractor '
OWNER-BUILDER DECLAPIATION PROPOSED CITY Ur uUrCr51 mio
I hereby affirm that I em 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's License Law(Chapter g(commencing with Section 7000)of Division 3 of the t t
Susinese and Professions,Code)or that he Is exempt therefrom and the heels for the alleged ASPHALT SHINGLES �/� e-D
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to /
e civil penalty of not more than live hundred dollars($500).):
E]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.70",Business and Profes.
slons Code:The Contractor's License Law does not apply to an owner at 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.If,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.).
❑1,as owner of the properly,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors 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 contrector(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
E]I am exempt under Sec. ,S 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:
❑1 have and w111 maintain a Certificate of Consent to self-insure for Worker's Compensation, / )/ Building as,provided for by Section 3700 of the Labor Cotle,for the performance of the work for which this /O/ / I O/ g
thermitbar suedCode. //�7/ L� / l� /1•• S61�fT1(C!
Zqd have and will maintain Worker's Compensation Insurance,as,required by Section 3700 of \LU `— -
Co bor Cade,for the performance of the work for which This permit is issued.My Worker's
Companaetl�on`In�eu'pn�ce cerrl�er e�ntl�Policy�number are: Tota
Carrier_.1s��. lCr— Policy Nos25S-96—x.3 Z2' PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
r COMPENSATION INSURANCE N.C.] I e
(This section need not be completed II the permit is for one hundred tlollere($100)ar lase.)
I certify that In the performance of the work for which this permit Is Issued I shall not employ
any person inanymanner so as,to become subject to the Workers'Compensation Laws of Cell- All roofs Shall be Inspected prior to any r0 ting material being
1°`nla. � installed. If a roof is installed without first obtaining an
Date /d 9y Appncant B inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It,after making this Certl cafe of Exi mptlon,you sh d become Applicant understands and will Comply subject to the Workers'Compensation provisions of the Labor Coda,you must forthwith comply pP ply with all non point
with such provisions or this permit shall be deemed revoked. Source regulations.
I certify that I have read this application and state that the above Information is correct.)agree
to comply with all city and county ordinances and erste lane relating e-building construction,f end AIIAII roof c9Ver t0 'O"Of better. /O�
hereby authorize cityrepresentativesunty of this cies to enter upon the above-mentioned property for and
sp(We) purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against Ilablifflee, /
judgments,coats and expenses which may In any way accrue against said City In consequence
of the granting of this permit. SIGNATURF/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