R-5625 APPLICATION FOR CITY of cuPeRTINo
NU a RR- 5625
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
'
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
WI180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
107456 it l l co V"a RESIDENTIAL COMMERCIAL OTHER
OWNER'S o �^ HAZARDOUS FIRE AREA
NAME Pa [,t, vn a �/ Q S
YES ❑ It yes-I understand ire a Class A
roof assembly is required.
NO tnigal I.C.B.O.q
ADDRESS y5;q,rA e— EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COV RINGS I
CONTRACTOR'S L -
NAME
,T a S, TO BE REMOVED TO BE RETAINED
ADDRESSR O TYPE OF ROOF COVERING
CITY&ZIP (�jJ 1...� EXISTING
�S Gaf'os.
PHONE ' BUILT-UP ROOF ❑
LICENSE //
NUMBER - LO ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
hereby affirm that i am licensed under provisions of Chapter a(commencing with section WOOD SHAKES -
]000)of Division 3 of the Business and Prolessian9 Code,and my license is in full torte and
effect' i/ 2[/(� WOOD SHINGLES
License Class Lic.Number / `( / ❑ _
OTHER(SPECIFY) ❑
Dale Contractor
OWNER-BUILDER DECLARATION PROPOSED
hereby affirm that am exempt from the e: Any city License Lew for the requires
. reason.
(Sec.7031 alt Business and Professions Code: Any city or county which requires a permit to
construct,alter,Improve,to file siorrepairenystructure,prior toils issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to fila a signed statement that g Is licensed 7000)of
the provisions
' of the ss and Pro License Law(Chapter a(commencing with omSectionand]000)of for the 3 0/the
Business and Professions Code)or that he is exempt therefrom entl the heals far 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(h wag):
❑leas and wner
sthctureI not
tendedmy employeeswithfor
s(S c.7heir sola compensation,snProfes-
sions
s- WOOD SHAKES ❑
the work,entl the structure Is not InsenLaw ores not for sale(Sec.]044,property
and builds
or
e$thereon,
The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑
improves thereon,end who doessuchwork himself or through his own employees,provided that
such improvements are not intended or owned for Bale.ill however,the building or Improvement
not but wk rimprve for purpose
stheowner-builderwill have the burden of proving that he did OTHER (SPECIFY) ❑ li^IIa'-slfl 7[
not builtl or improve for purpose oYseleJ.
❑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 Contractors License Law. PROVIDE MFGR. INSTALLATION SPECS.
❑1 am exempt under Sac. ,B&P.C.for this reason
Owner Date APPLICATLOtbDATE VALUATION PERMIT
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
Fj I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, B I
as Is
for by Section 3700 of the Labor Code,lar the performance of the work far which thi3
permit 9149uetl. - ® Se
�]I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of l�
the Leber ode, r the dormant,of the work for which this permit is Issued.My Worker's U c` /✓ Ze 0 Tota
�Cempen t n In uran rrierand
Palicy number ere: V
i carrier Policy No. ( /L J j,,\1PERMIT AUTHORIZATION DATE
CERTIFICA E OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.p 1?1 Lill
(This section need not be completed if the permit is for one hundred dollars($100)or less.)
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 Ceti- All roofs shall be Ins cted prior to any roofing material being
Ionia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO become
subject to the Workers'Compensation proviPLICANT: It.after sions of the Labor Code,s Certificate of you must forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shalCbe 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 state laws relating to building construction,and All rOOf verings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in. G
apache)purposes. �—G .S
(We)agora to save,indemnify and keep harmless the City ai Cupertino against liabilities, 7 /
of the gran costs and expenses which may in any way accrue against said City In consequence 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