R-5526 PERMIT R-
APPLICATION .5526
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
IN DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
O / Z / I'N od r GT RESIDENTIAL COMMERCIAL OTHER
OWNER'S }� HAZARDOUS FIRE AREA
NAME r? D 49 0 2~ � Al YES ❑ If yeas I understand that. Class A
rayl assembly is required.
NO - Initial I.C.B.O.k
ADDRESS " A +E EXISTING ROOF COVERING
PHONE OF Z 2 G 9 NUMBER OF EXISTING COVERINGS
CONTRAC 'S
NAME G G t, 2 er TO BE REMOVED TO BE RETAINED
ADDRESS �O TYPE OF ROOF COVERING
CITY B ZIP / IN • W9 fiNC 72 *U 11i
t' EXISTING
PHONE &-i 77G - 2-6, 75— BUILT-UP ROOF ❑
LICENSE .
NUMBER TTP 3 S ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect. WOOD SHINGLES
ElLicense Class c 99 Dc.Number ?
fi'/ � �7 OTHER(SPECIFY)
Date i/ 9Contractor
OWNER-BUILDER DECLARATION -- 7— PROPOSED 3 f
hereby affirm that 1 am exempt from the e:Contractor'scity License Law for the following reason. /
(Sac.70315,Business and Professions Code: Any city or county which requires a permit to
construct,alter,Improve,demoto file signed air statny ement that
is licenseor to Issuance,puruantelsoreprovisthe BUILT-UP ROOF ❑
applicant for such permittoflaw a signed statement that g Is licensed pursuant to the provisions
of the ss an Pro License Law(Chapter h(commencing with Section 7000)of for the 301 the
• Business and Professions Code)or thet he is exempt therefrom and the basis for the applicant
to ASPHALT SHINGLES
exemption.Anyviolationnot Section five70315byanyapplicantforapermit subjects the applicant Io
a civil penalty of not a re property,
floe by dredemployees
dollyeesrs(h wag 1: WOOD SHAKES
❑I,as owner of the property,or to employees with wages as their sale compensation,will do ❑
the work,and the structure Is not Intended ores not for sale(Sea owner
of Business and builds
Profes-
sions Code:The Contractor's License Law dams not apply to or through
owner of property who builtls or WOOD SHINGLES ❑
Improves Thereon,and who does such workhimselffor orthrough hie own employees,provided that
suchimprovements years not pletin,ended orownetlfor sale, ill however.the euof pring os improvement
is sold ntbuild orI prove for purposetof sthe owner-builderwill 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 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 Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for this reason
OwnerDate
WORKER'S COMPENSATION DECLARATION APPLICATIO E VALUATION PERMIT F E
I hereby affirm under penalty of perjury one of the following declaration: $y y
$I have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, 61 d Building
as rovlded for by Section 3700 of the Labor Code,for the performance of the work for which thisT1. _
permit is Issued. I r
El I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of H `Vl-'�kr,,I'0 1 /Ml Seismic
the Labor Code,for the performance of the work for which this permit is issued.My Worker's N \�U�`•v
Compensation Insurance carrier and Policy number are: Total
Carrier 37T1!g T If /e""i0 Policy No.jf s'97 (/ //TJ PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed If the permit is for one hundred dollars($100)or less.)
I 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 call- All roofs shall be inspected prior to angToofilig material being
fornia. installed. If a roof is installed without first obtaining an
Date L Applicant � � inspection,I agree to remove all new materials for inspection.
N TICE T- APPLICANT: If,after making this Certificate of Exemption,you should b come Applicant understands and will comply with all non pint
subject to the Workers'Compensation provisions of the Labor Code,you 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 be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In- /
apache)purposes.
(We)agree to save,pe Indemnify w and keep hay a y the City ai Cupertino against liabilities,
ence
of The grant ngsts and of this permitsas which may in any way accrue against said City In consequence SIGNATURE OF 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