R 5925 APPLICATION FOR CITY OF CUPERTINO NUMBER R— 5925
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT 4 4OB)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
• BUILDING ADDRESS- ///
RESIDENTIAL — COMMERCIAL OTHER
-
HAZARDOUS
!'/ry HAZARDOUS FIRE AREA
NAME Lt(/ �OYGS / �(R( /�(1 T / SES ❑ If yes s I understand iced.hat Clan A
roof —I un ty is required.
�
/ �j�j O ❑ Initial I.C.B.O.a
ADDRESS f/ 7 ��/ yY_ ^C J.
cam, O_- gyZe EXISTING ROOF COVERING
PHONE
/a'� f/A NUMBER OF EXISTING COVERINGS l
CONTRA
C R'S
TO BE REMOVED_L_TO BE RETAINED
NAME
&i
�y TYPE OF ROOF COVERING '
CITY 8 ZIP /
EXISTING
PHONE !kAv L3�-1,2 33 BUILT-UP ROOF ❑
LICENSE �
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter g(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is in full force and11
ansa. c.� 1r, 154 OD SHINGLES ❑
License Class Lic.Number �f(p
SPECIFY) ❑
Date Deallaem!
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that 1 amexampt from the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city of county which requires a permit to
construct,alter,Improve.demolish,or repair any structure.prior to Its Issuance,also requires the BUILT-UP ROOF
applicant for such permit to fila a signed statement that he Is licensed pursuant to the provisions 16
of the Contractor's License Law(Chapter 8(commencing with Section 7000)of Division 3 of the
•
exemption.
and violation o Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES �` ❑ _�
exemption.Any Professors
of Sadden 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500).):
❑1,as owner of the property,or my employees with wages es their sole compensation,will do WOOD SHAKES 1
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Protest- ``G Y �XQ1V
alone Code:The Cent clots License Law does not apply to an owner of property who builds or WOOD SHINGLES �G�
Improves thereon,end 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 V
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) Gov JC ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,em 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 c m exempt
ulicensedrSe pursuant to the Contractors License Lew. PROVIDE MFGR.INSTALLATION.SPECS.��.
❑I em exempt antler Sec. ,B 8 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, Building 1 y�
an provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is Issued. Q A
E]I have and will maintain Workers Compensation Insurance,as required by Section 3700 of v 1 `' Seismic
,the Labor de,for the performen 1 the work for which this permit Is Issued.My Workers
Compact onlnsurancecarriers eI ynumb are: Total
cam / O "bIIcy No4.
PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.]
(This section need not be completed It the permit Is for one hundred dollars($100)or lose.) 1 n. /k I O —9a
I certlty that In the performance of the work for which this permit is Issued,I Shall not employ l../V 1^ 1
any person In any manner so as to become subject to the workers'Compensation Laws of can. All roofs shall be inspected prior to any roofing material being
forma. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICecome
subject to the WTO orkers'Compensation proviPLICANT: If,after sionls ofsthe lLabor Code,cate of you mustufothwou lithbcomply Applicant understands and will comply with all non point
with such provisions or this permit shalfbe deemed revoked. SOUfCe regulations.
I certify that l have read this applicallon and state that the above information Is correct.I agree
to comply with all city and county ordinances and State laws reletingto building construction,and All roof coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against ilabllltlee,
judgments,coals and expenses which may In any way accrue against said City in consequence
=fan's gmnlmg of this permit. SIGNATURE OF AP ICANT 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