R-5386 PERMIT R_ 5386
APPLICATION FOR CITY of CUPERTINO NUMBER
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 ((//�� //��� �
z I D I Q�d� ►1 �/u r4 RESIDENTIAL COMMERCIAL OTHER
OWNER'S 1 I HAZARDOUS FIRE AREA
✓-I/� -iT/1 ✓l YES ❑ If yes-I understand that a Class A
NAME 1•�4 I ILIA roof assembly is required.
CL NO � Inlbal I.C.B.O.N
G0�ADDRESS Did -FauDn W�-rT EXISTING RID OVERIN
PHONE /D NUMBER OF EXISTING COVERING
CONTR TOR'S I l.._,0i Pa.&T7 O
qf(��(�J rjl TO BE REMOVED_ -TO BE RETAINED
NAME_ n
ADORES$ I -,�I g.1.. ,1 I„ /) r�� TYPE OF ROOF COVERING
�
CITY a zlP —�+ Lim EXISTING
PHONE •7' �IL�I co
BUILT-UP ROOF ❑
LICENSE
NUMBER �(0`9 /(Da W ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em 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.
��yY WOOD SHINGLES ❑
Llconee Cl s v✓`" Lic.Numb r � -
Date a� jr OTHER (SPECIFY) ❑
OWNER-BUILDS DECLARATION 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
construct,alter,improve,demolish,or repair any structure,prior to its Issuance,also requires the BUILT-UP ROOF
of the nt for such Permit to file a signed statement that g is licensed Pursuant to the Provisions
of the Contractor's License Lew(Chapter 9(commencing h with Section pursuant
of Division 3 of the D
Business and Professions Cade)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES DEC
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to G
a civil penalty of not mora than five hundred dollars($500).): WOOD SHAKES G V rip
❑1,as owner of the property,or my employees with wages as their sole compensation,will do 0
CITY 1CllY
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Prates- r 1
$ions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES V Lula;
Improves thereon,and who does such work himself or through his own employees,provided that u{
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 Professions Cotle:The Contractor's License Law tloes 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 MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: I
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compensellon, I Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for whichthis
peRl isissued. 2I 1 I2' Seismichave and will mountain Worker's Compensation Insurance,as required by Section 3700 of I
the Labor Code,for the performance of the work for which this permit Is issued.My Worker's
Comperri n Inssur nce c entl Poll y number are: Total
Carrier _ Policylrw5� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(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 shall 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.
subjl�to thCE eOWorrkerss'Compensallon proivisions ofthlelcate of Labor Code,you must forthwou id become
th comply Applicant understands and will comply with all non point
with such provisions or this permit shell 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,entl r00}COVer10 Sto be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mention id property for in- f III
spection purposes. n
• (We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may in any way accrue against said City in consequence SIGNATIJFJE OF APP ICANT 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY