R-5420 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R" 5420
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 1' ^ x
06 RESIDENTIAL , ` COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
r YES ❑ If yes-I understand that a Class A
NAME iif O 1 `p,�` a roof assembly is required..
NOInitial I.C.B.O.N
�
ADDRESS i��1N WC 006 , cfij! �nit EXISTING ROOF COVERING
X1
PHONE 0 -5?A NUMBER OF EXISTING COVERINGS COP,
CONTRACTOR'S /� []
`.'�,.\Q `'�^x�,y ff4 , \tom/' TO BE REMOVED y1�TO BE RETAINED
NAME \ 1 U��(J C, K-•LX.11`\ ri/1 \ 1�-
ADDRESS - TYPE OF ROOF COVERING
CITY&ZIP N , `iI V lc M I f.Ilei ye '
CApl 2t) 1056q�_/ l51 EXfSTING
PHONE 1O) BUILT-UP ROOF
LICENSE
NUMBER D - ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect.
�l//�� 3.1 A qQ WOOD SHINGLES ❑
License Cis ea S.�„LL_ Lic.Number OI 'T r l
17•� -a-1 \ otn5,Y)le gobfiYIol OTHER(SPECIFY) ❑
Date Contractor
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors License Lew for the following reason. �1 p
(Sac.7031.5,Business and Professions Code: Any city or county which requires a permit to W
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 proyti Ions � T O
of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he Is exempt therefrom and ins basis for the alleged ASPHALT SHINGL (S�
ry
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to /xl
a civil penalty of not more than five hundred delta.($500).): WOOD SHAKES
ry Vf LVr
❑I,as owner of the property,or my employees with wages as their sole compensation,will do tk f�J
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profes.
sions Code:The Contractors License Law does not apply to an owner of 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 bullding or Improvement
Is soldwithin one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not bulid 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.
❑1 am exempt under Sec. .B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION P EE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: ��
❑I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, I n
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this /
permit is issued. $BIS
grhave and will maintain Worker's Compensation Insurance,as required by Section 3700 of
the Labor Code,for the performance of the work for which this permit Is Issued.My Workers T.
Compensation Insurance carrier and Policynumberare: /�?)A]
j ''I
Carrier "�x\Ux•4Ix CMQ\C Policy No.gWr?)l Il� PERMIT AUTHORIZATION DATE
CER IFICAT F EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑ `� •C•A
(This section need not be completed if the permit Is for one hundred dollars($100)or less.) 6 •'1
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 Workers'Compensation Laws of Call- All roofs shall b6 in ed prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
edos' If,
pisthis
Certificate
rt become
sue to the orrkersCompensatlon rovins ofthe LaboCode,you must forthwith 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 read this application and state that the above Information is correctI agree
to comply with all city and county ordinances and state laws relating to building construction,and All r00{h coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
hereby
purposes. .(//111/.�•hW/V/A,I/^,^' �D/1
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
' judgments,costa and expenses which may In any way accrue against said City In consequanoe 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