R-5436 PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 5 4 3 6 . -
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
1&0 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS /
e!/pE/L Ti�/o, eR• ` SQ /T RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
L ��2- �pn/ChcA YES F] If yes—I understand that a Class A
NAME roof assembly is required.
_SAI
Initial I.C.B.O.M
ADOREss 'S/7 "E c / / EXISTING ROOF COVERING
PHONE O v ( /d` NUMBER OF EXISTING COVER GS
CONTRAC R'S
TO BE REMOVED TO BE RETAINED
NAME �++`�+�V �•_
ADDRESS _ TYPE OF ROOF COVERING:
CITY&ZIP
EXISTING
PHONE BUILT-UP ROOF ❑
LICENSE ❑
NUMBER - ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
hereby affirm that I em licensed under provisions of Chapter y(commencing with Section WOOD SHAKES ❑
7000)of Division 3 0l the Business and Professions Code,and my license Is In full lona an
effect.
OD SHINGLES
License Class LIc.Number
Date Contractor
(SPECIFY) ❑
OWNER-BUILDER DECLARATION P D
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
construct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the B ILT-UP ROOF
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Law(Chapter a(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES
exemption.Any violation of Seaton 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($5001): WOOD SHAKES
1]I,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 Contractors License Law dose 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 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 Professors 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 Lew. PROVIDE MFGR. INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
ner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: p
C1I have end will maintain a Certificate of Consent to self-insure for Worker's Compensation, W D Buildin
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this g
permit isvIssued.
0/�C/� Seismic �'
❑I have end will maintain Worker's Compensation Insurance,as required by Section 3700 of �/(%T O 1
the Labor Code,for the performance of the work for which this permit Is issued.My Worker's I
Compensation Insurance carrier and Policy number are: C'TY rfFTotal i
Carrier Policy No. PERiOrrWr libArZATiON DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.OQ
(This section need not be completed If the permit is for one hundred dollars($100)or less.)
1 certify that in the performance of the work for which this permit Is Issued,I shell not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Cali. All roofs shall be inspected 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.
NOT CE TO APPLICANT: ecome
subject t.the Workkers'C mpefnsallon,after making
oftheflLabor Coca cate of you must forthwithcomplyApplicant understands and will comply with all non point
with such provlalons 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 roof coverings eclass" "or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-spection purposes.
iJ Al
(We)agree to save,Indemnity and keep harmless the City of Cupertino against Ilabllitles,
judgments.costa and expenses which may In any way accrue against said City In coseuece
ofIRagrantingofthispermit. SIGNATURE OF APPLICANT ATE
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
f
__ OFFICE COPY