R-5443 APPLICATION FOR CITY OF CUPERTINo
NUMMI R R- 5443
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
190 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAMEColl assembly is required.
NO Initial I.C.B.O.k
ADDRESS
EXISTING ROOF COVERING PHONE NUMBER OF EXISTING COVERINGS I1
CONTRACTOR'S
IV
r TO BE REMOVED TO BE RETAINED
NAME /I
ADDRESS TYPE OF ROOF COVERING
PHONE ZIP /6to tax
D,TV 8 EXISTING r.. s.
�a��yb , BUILT-UP ROOF ❑
LICENSE
NUMBER Z Z ASPHALT SHINGLES 13
LICENSED CONTRACTORS DECLARATION
l.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 ar
affect. V Ly r
WOOD SHINGLES ❑
License Class Lie.Number
Date! Zdr_� 9 1— Contractor Ja r l/�� OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason. 100
(Sec.7031.5,Business and Professions Code; Any city or county which requires a permit to
applicant
demolish,sign dstirementhatstructure,prior tolls Issuance,pursuant alsorequkes the BUILT-UP ROOF /�
applicant far such permit to Ills a signed statement that he Is licensed pursuant to the provisions 0
of the Contractors License Lew(Chapter 9(commencing with Section 7000)of Division 3 of the
. Business and Professionsof Code)or that he is exempt therefrom and the bass for the alleged ASPHALT SHINGLES
exemption.Anyviolationo t more
of than
live hundred
by any applicant for a permit subjects the applicant to
a civil penalty et not more ,or huntlretl tlouars(h wag): WOOD SHAKES
I,as owner ofthe property,or tmy eemployeeswith wages as their sole compensation,will J
the work,and the structure Is not Intended ornot for sale(Sea owner
of Business and Profen 7�
sons Code:The Contractor's License law does ielf rapply to through his own
employers,pho rovide ds or WOOD SHINGLES ❑
improves thereon,and who does such work himself or through his own employees,improvement provided that
such improvements are not completion,
leb n,or offered for seer. ill however,the en of pr or improvement
IS notsold bull or improve
for purpose
the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build as
improve for purpose of sale.).
I,ec owner of the property,am exclusivelycontractingCod ting with licensedcontractors License
ice sere to construct
the protect(Sec. of pr Business and Professions Code:The Contractor'srcts for
Law does rojnot PROVIDE LC.B.O.REPORT NO.
apply to contractor(s)
ntownerof property who pursuant
orImproves thereon,and who contracts for such projects
with a c m ex m pt)under
a pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑I em exempt under Sac. ,B 8 P.C.for this reason
Owner Date APPLICATION VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: A"�
❑ have and will maintaion in a Certificate of Consent to self-insure for Worker's Compeor nsation,this �/V 6)T BU
as provided lar by nd will aintai a of Certificate
Labor Code,for the performance for
rer'sC mpenshioi, r6J
permit is Issued. C flj
❑1 have and will maintain Workers Compensation Insurance,as required by Section 3700 of /��(J/-C. W
-the Labor Code,for the performance of the work for which this permit Is Issued.My Workers VFC/7 r A/O Total
Compensation Insurance carrier and Policynumberare: +
Carrier Policy Policy N / � PERMIT AUTHORI DATE
CERTI KATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section nerd not be completed If the permit Is for one hundred dollars($100)or lass.)
I certify that In the performance of the work for which this permit Is Issued,I shall not employ
any parson in any manner so as to become subjectto the Workers' ompana on Laws of Cell. All roof:: h I be inspected to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date _ I Applicant inspection,I agree to remove all new materials for inspection.
etoReAPPLICANT:
ers'Cafter lsfiruttlbecome
subject Wsopensatprovisions of the Labor you must forthwith Applicant understands and will comply with all non point
with such provisions or this permit shalC,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 roof coverin Sto be ss"C"or better.
hereby authorize representatives of this city to enter upon the above-menlloned property for in-
spection purposes. 6 aaI—�
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, i �I� 40 ply
judgments,costs and expenses which may In any way accrue against said City In consequenceoe
S NATURE APPLICANT DATE
of the granting of INS 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