R 5216 PERMIT R_ 5 216
APPLICATION FOR CITY of CUPERTINO NUMBER
INSPECTION DIVISION P RMI"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
Q ` ' l I
/ 0 V Z IV(, I RESIDENTIAL ✓^ COMMERCIAL OTHER
owNER'S HAZARDOUS FIRE AREA
YES ❑ It yes—I understand that a Class A
NAME NO of assembly is required.
Initiel I.C.B.O.#
ADDRESS EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
r -
CONTRACTOR'S
� � O TO BE REMOVED TO BE RETAINED
NAME '�/
ADDRESS may' zL r f TYPE OF ROOF COVERING
CITY BZIP O `� 4 C EXISTING�,�(
PHONE 1 tJ SC !' - BUILT-UP ROOFLICENSE
❑
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em 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 ❑
License Class C Lic.Number
/'� r OTHER SPECIFY
Date ^ Contra 'U I/ Q A (SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affBuIrM that em exempt from the e: Any
or roue Law for the follow(a anti t.
(Sec.703/S,Business and Profedemolish,
r rep Code: Any dry or county which requires a uirmll to
construct,error,Improve,to file signed statair eny mentrthate,Iprior to s licensed
Issuance,pursuant toalso requlreethe BUILT-UP ROOF
of theantforsuch permit to flaw asignedr 9(coenttnwthe ith Sectio pursuant to the provisions A
of the ss and
License Professions
Law(Chapter a Is ex a pt(�wllh Section 7000)of for the 3 0l the
Budmee entl violation of Code)or that he le exempt therefrom and the Deal°for the scant to ASPHALT SHINGLES
exemption.pen.Anyt violation more
of Section 703 hundred
by any applicant for a permit subjects the applicant to
e civil penalty et not more then live by employees
offeyees w th wage L�
Iwork, Ownerofstructure
Is not I tended oyeeered wages as(Sec,their Bole compensation,will s. WOOD SHAKES
the work,and the structure Is not Intended ores not for y to n Owner
of property
end Pros or
Ilona Code:The,and
License LewO imnotapplytosnowner ofproperty whoidedtar WOOD SHINGLES ❑
Improves thereon,and who does such work himself or through his own employees,provided that
such Improvements aro not completion,
leb n,or owner-builder
for leer.ill however,the buildingof pr or Improvement
is not ld build
Improve
for purpose
sthe ownerbullder will have the buroen of proving that he tlld OTHER(SPECIFY)' not bulltl or Improve for purpose of sale.). ❑
01,as owner of the property,em exclusively controclln with licenced contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Law dose 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 Lew, PROVIDE MFG R.INSTALLATION SPECS.
EJI em exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLIQ�IT TE LUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a of the
of Consent to self-insuredorm for Worker's Compensation, I O�. OO Buildin�
as provided for by Section 3700 0l the Labor Code,forme performance of the work for welch this
permit Is Issued. Seismic —0
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of TV
the Labor Code,for the performance of the work for which this permit is Issued.My Worker's )1, OF ``UH:
Compensation Insurance carrier and Policy number are: fi I IN Total
arrear Policy No. 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 lose.)
I cartery that In the performance of the work for which this permit Is Issued,t shall not amtoy
any person In any mann Laws e
r so ee to become aublear to the Wo rare'Com ensateon Ll fan- All roofs snail a inspected prior to any roofing material being
lornl°' installed. If a roof is installed without first obtaining an
Date 6 Applicant w inspection,I agree to remove all new materials for inspection.
subject to me Workers'C mpensetion proafters alonle of theflcate r LaborCode,yolu n, should become
st fothwith comply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. Source regulations.
I certify that I have reed this applicetlon 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 t 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°eve,Indemnify and keep harmless the City of Cupertino a alnst liabilities,
jutlgmenta,cast°end expenses which may In any way accrue against said Clty4n conerquencr
of the granting of this permit. 81
NATURE OF APPLICANT D E
PRE-INSPECTION: PLYWOOD: r 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