R-5442 PERMIT _
APPLICATION FOR CITY OF CUPERTINO NUMBER R 5 4 4 2 .
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(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
/OZ/t flwool Ar•
RESIDENTIAL—X— COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
NAME YES roof assembly iItyes-lunderss required. Class A
N Initial I.C.B.O.#
ADDRESS EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACT 'S }
NAME G• TO BE REMOVED TO BE RETAINED
ADDRESSJ s. S. T -9r//C
r� TYPE OF ROOF COVERING
CITYBzIP V •J I
PHON��/ G �/ EXISTING
yD Z7 � / BUILT-UP ROOF . ❑
LICENSE
NUMBER Z 3 L ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION /
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES y5
7000)of Division 3 of the Business and Professions Code,and my license Is in full force and
Leant. 0090
3 7z WOOD SHINGLES . ElLicense Class !�_ I Num ber
Date ��U+ w f 7 Contractor OTHER(SPECIFY) ❑
OWNER BUILDER DECLARATION PROPOSED
hereby affirm Bu that am exempt from the Contractor's License Law for the following reason.
(Sec.70315,Business and demolish,
or rep Code: Any city or county which requires e permit to �J
construct, er,such
Improve,to file asi n repair anystructure,he prior lJcenso Issuance pursuant to therequires the BUILT-UP ROOF [I
applicant for such permit a file a signed statement that he is Ilcansetl pursuant to the provisions
of the <�
of the Contractor's License Lew(Chapter 9(commencing with Section 7000)of Division 3 of the
•
exemption.
and Professions Code)or that he Is exempt therefrom and the belle for athepp alleged ASPHALT SHINGLES
exemption.Anyf violation more
of Section hundred
by any applicant for a permit subjects the applicant to
e civil penalty of not mare then flue hundred dollars($500).):
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not intended or offered for safe(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.If,however,the building or improvement
leaoId 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]I,as owner of the property,am exclusively contracting with licensed contractors to Construct
the project(Sac.7044,Business and Professions Code:The Contractors 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.
C]I am exempt under Sec. ,B 8 P.C.for this reason
Owner Aare APPLICATION DATE L TION PERM T F
WORKER'S COMPENSATION DECLARATION � EE
hereby affirm under penally of perjury one of the following declaration:
for Wo AU Q� Y�� B l
❑I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, �/ FI 'fa/L1
as provided for by Section 3700 of the Labor Coda,for the performance of the work for which this
permit Is issued. T�' Bel IC
I]1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of CITY 01:C 1F
the Labor Cotle,for the performance of the work for which this permit Is issued.My Worker's trV E`'
Compensation Insurance carrier and Policy number are: HrINU Total
Carriers �t/w/V PolicyNo.!m, PERMIT AUTHORIZATION DATE
CC RTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.I]
(This Sactlon need not be completed If the permit is for one hundred dollars($100)or leas.)
I certify that in the performance of the work for which this permit Is Issued,I sh not employ
any person In any manner so as to become subject to the Workers' mpanes awe of call. All roofs shall be inspected prior to Thy roofing mat rial being
fornia, o 7 installed. If a roof is installed without first obtaining an
Data v��r- / • Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: II,after making this Certificate of Exei6ii you should become Applicant understands and WIII comply with LII non point
subject to the Workers'Compensation provisions of the Labor Cod . ou must forthwith comply pP p y p
with such provisions 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 All roof coverings to b lass"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes.
(We)agree to save.Indemnity and keep harmless the City of Cupertino against liabilities, `
judgments,of costs
of anthid expenses which may in any way accrue against said City in consequence $GNATU APPLICANT DATE
• 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