R-5392•
•
OFFICE COPY
NUMB R R- 5392
APPLICATION FOR CITY OF CUPERTINO
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
• WITHIN 100 DAYS OF PERMIT ISSUANCE OR
' 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
./
V1 J t iROVit/
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
lb yyp L_Q>W oo P�
that Class A
YES ❑ If yes -roof
NAME 1�
as emblyunderstand
required.
roof assembly is required.
NO C3Initial I.C.B.O. M
clu?6R (C-3 O
ADDRESS k
EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS I
7,63 —'
PHONE `-{
CONTRACTOR'S
'
rte/ c p /D
M o a
TO BE REMOVED TO BE RETAINED
NAME
I re --cm
�!`�1.`t�{! A.�.�' �/IGI iI
ADDRESS i t , �^
TYPE OF ROOF COVERING
�i Wy
CIN&ZIP 10.C'1 l
EXISTING
/l/y✓
l
295--�5- ��
L
PHONE 1
BUILT-UP ROOF
LICENSE
NUMBER ����
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
hereby underPprovisions(commencing
by affix
affirm that em licensed under onof Chapter a (commenting with Sectionand
licns a
WOOD SHAKES ❑
7000) of Di 3 of the and rofessions Coda, and my license is In full force entl
effect.
WOOD SHINGLES ❑
License Class Lip. Number
�,S
OTHER (SPECIFY) El
Date Contractor
PROPOSED �3X
OWNER -BUILDER DECLARATION
hereby affirm that em exempt from the Contractor's License Lew for the following reason.
in e permit to
(Sec. 7ct, BImprove and Professions Code: Any city or county which re,
3/
alt anyentrthat re,he prior to Its Issuance, also the
construct, alter, improve, demoto
BUILT-UP ROOF ❑ 9
file signed sta he lith to therequires ovist
applicant for such permit to flaw a signed statement pursuant t0 the provisions
Of the Contractor's License Lew (Chapter 8 nci
commencing with Section 7000) of
Sectio the
the a of the
and Professions Code) or that he Is exempt therefrom and the baste for the
Is ex for
ASPHALT SHINGLES ❑
exemption.
exemption. Any violation of by any applicant for a permit subjects the applicant to
applicant
hanWe hundred
e civil penalty Of not more than five huntlretl tlollere ($500).):
WOOD SHAKES
E) 1. 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 (See. 7044, Business and Profes.
Ions Code: The Contractor's License Lew does not apply t0 an owner of property who builds or
WOOD SHINGLES
thereon, and who does such work himself or through his own employees, provided that
1:1mprove.
such Improvements are not Intended or offered for sale. If, however, the building or Improvement
Is sold within one year of completion, the owner-bullder 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 Contractors) licensed pursuant to the Contractor's License Law.
PROVIDE MFGR. INSTALLATION SPECS.
❑ 1 am exempt under Sec. ,B 8 P. C. for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION
PERMIT FEE
�S
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,
b/
Building
provided for by Section 3700 of the Labor Cotle, for the performance of the work for which this
permit is Issued.
❑ have and will Worker's Compensation Insurance, as required by Seaton of
1
CT'1 ��
/!��\
Seismic
the Labor Code, for the performance of the work for which this permit Is Issued. My Worker's
the performance the wokfor Worker's
//�� /I(•
Compensation Insurance carrier and Policy number are: lx')
(J!• 1
lJJ v
Total
P RMITAUTHORIZATION
DATE
Carrier Policy No.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(Title section peed not be Completed if the permit Is for one hundred dollars ($100) Or lees.)
I certify that In the performance of the work for which this permit Is Issued, I shall not employ
any person In any manner so as to become subject to the wprk�s' Coln anon Lewe of ca11-
All roofs shall be inspected prior to any roofing material being
form'$. (n `___.c�Z)
I
installed. If a roof is installed without first obtaining an
Date 1� Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE OAP LICANT: IL alter making this Certificate of Exemption, you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
Applicant understands and will comply with all non point
with such provisions or this permit shell be deemed revoked,
source regulations.
I certify that I have read this application and state that the above Information Is correct.I agree
to comply with all city and county ordinances and elate laws relating to building construction, and
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
heron
All roof coverings to be clas or better.
IJ/�
purposes.
T:�
I ` T
(We) agree to save, Indemnify and keep harmless the City of Cupertino against liabilities,
�d
judgments, coats and expenses which may In any way accrue against said City In consequence
of the granting of this permit.
SIGNATURE 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