R-5719 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- IJ 719
INSPECTION DIVISION. PERMIT EXPIRATION
REROOF PERMIT (408) 777-3226 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
�'. BUILDING ADDRESS
1
O if l RESIDENTIAL COMMERCIAL OTHER
OWNER'S ,,// (10-, HAZARDOUS FIRE AREA
NAME `-""s`1 W �k G' YES ❑ It yes-1 understand that a Class A
roof assembly is required.
NO ❑ Initial 1.10.13.0.N
ADDRESS n//�� L-0K j&)OOd.D(-. EXISTING ROOF COVERING
—
PHONE �l0 3 I NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME 5 �� ! '� �'I J TO BE REMOVED TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
clrY s ZIP 76,:, -S kn6, I At
EXISTING
PHONE 44 ZSS BUILT-UP ROOF ❑
LICENSE /
NUMBER 37 Zd ASPHALT SHINGLES ❑ l/
LICENSED CONTRACTORS DECLARATION
hereby iaffirmnion that em licensetl under Professions
of Chapter 9(commencing with Section WOOD SHAKES
]000)of Division 3 of the Business and Proleselone Code,and my license Is In lull force and
License Claes
affect. Llc.Number
ZtJ WOOD SHINGLES ❑
Date Contractor OTHER(SPECIFY)
OWNER.BUILDERSeCCAR&Ig PROPOSED
I hereby affirm that I am 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 Nin / 6 REE-U l
construct,alter,Improve,demolish,of repair any structure,prior to Its issuance,also requires the BUILT-UP ROOF IiCh
applicant for such permit to He a signed statement that he Is licensed pursuant to the provisions
of the Contractois License Lew(Chapter 9(commencing with Section 7000)of DlvleIon 3 0f the
Business and Professions Code)Or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES
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($500).): WOOD SHAKES
C]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(Sec.7044,Business and Profes.
sions Code:The Contractor's 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.II,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.). -
❑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 contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE fill INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm untler penalty of perjury one of the following declaration: Z7, o
as Khave and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, Building
r itled for by Section 3700 of the Labor Cotle,for the performance of the work for which this
permit Is issued. Seismic 0
.D have entl will the performance
Worker's Compensation the work
for Insurance,as required is i by Section 3700's ( -
JheCo Labor Code,for the performance of the work for which this permit Is issued.My Worker's
Compensation Insurance carrier and Policy number are: [�� � Total 1 � O
Carrier �A/L4�� Policy No. `� PERMIT AUTHORIZATION DATE
�r IFIL/ OF EXEMPTION FROM WORKE
CGMPENSATION INSURANCE NCD
(This section need not be completed if the permit Is for one hundred dollars($100)or lana.)
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 Can- All roofs shall be inspected prior to any roofing material be ng
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOT CE TO APPLICANT: It.aftr makints became
subject t0 the Workers'Compensatl n provisions of theficate Labor Code,of yoiu must forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shelf;ba 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 slate laws relating to building construction,and All roof coverings to be class"C"Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection 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 In consequence FAP CANT DTE
. of the granting of this permit.
PRE-INSPECTION: PLYWOOD: I -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