R-5720 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 5720
• INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN,I80 DAYS OF PERMIT ISSUANCE OR
. 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
1094- 1 1 RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
NAMESC �II -' 4 VES ❑ If yes–I understand that a Class A
- f r /'e `� „ N A roof assembly is required:
NO Initial I.C.B.O.N
ADDRESS,1� �/t107 eRa
a b jyL-i (L-1i EXISTING ROOF COVERING
PHONE 4-1 S—Ilii r_'S NUMBER OF EXISTING COVERINGS If
CONTRAC S
NAME lrQ.Y1 Q i$ %.i H C e P-0 D-ILI V1 TO BE REMOVED TO BE RETAINED
ADDRESS 22�2 C O n /1-Ve S J �f 5-1 TYPE OF ROOF COVERING
CITY a ZIP tt 11 f EXISTING
PHONE —
BUILT-UP ROOF ❑
LICENSE S'sal'�3
NUMBER ASPHALT SHINGLEK2
LICENSED CONTRACTORS DECLARATION /
hereby affirm that em licensed under provlslons of Chapter B(commenting with Section WOOD SHAKES <��
7000)of Division 3 of the Business and Professions Code,and my license is In full force and
c
effect. WOOD SHINGLES G
License Class Lic.Number
f -
Date f0•-iii Conor Qa ft OL"'i U OTHER(SPECIFY) ❑
tract
OWNER-BUILDER DECLAR ION PROPOSED
• 1 hereby affirm that I am exempt hom 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 Contractors License Lew(Chapter I Commencing will Section 7000)of Division 3 ditto
—/
• Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLESP A LJy
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($501 �J�■
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKE'vVV10 VE1
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profee- 4p
Bions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINCtt}ESJr
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 LUY
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY)
thlfry(�
1 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 Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION 1r'--/�'/–//J'�yQ�['
I hereby and under maintain
a of perjury one of the following duce for Wo • �.J�
❑ have and will maintain a Certificate of Consent to sell-insure for Workers Compensation, BUllding
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this O J
permit Is Issued. It (
ve and will maintain Worker's Compensation Insurance,as required by Section 3700 al BeISmID
�,t–r�,:1.tf�'1
the Labor Code,for the performance of the work for which this permit is issued.My Worker's
Compensation Insu nae carrier and Policy number are: Total
Carriers C Fkm Policy Ne s—ol7--f322 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.O❑
(This section need not be completed If the permit Is for one hundred dollars($100)or leas.) 1` o
I certify that In the performance of the work for which this permit is Issued,I shall not employ If 41,
any person In any manner so as to become subject to the Workers'Compensation Laws of Cell- All roots shall-be inspected prior to any roofirig material being
10fria. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non
subject to the Workers'Compensation provisions of the labor Code,you must forthwith comply pP p y 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 I 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 clry to enter upon the above-mentioned Property br In.specti
herebon purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may in any way accrue against said City Inconsequence SIGNATURE OF APPLICANT DATE
• of the granting of this permit.
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