R 5302 PERMI
APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 5302
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
ISO DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL__X,_OTHER
OWNER'S ' lHAZARDOUS FIRE AREA
NAME ��'(� Q� I YES ❑ It yes—I understand that a Class
roof assembly is required.
NO Initial LC.B.O.M
ADDRESS. L 0 C1 1QG�. �.rjQ.. f EXISTING ROOF COVERING
PHONE 3 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME TO BE REMOVED ' TO BE RETAINED
AooREss: '� Q TYPE OF ROOF COVERING
CITVBZIP `� O t S J
� �('�$ [� EXISTING '
PHONEY\IO �+q I�-.p—IJP BUILT-UP ROOF
t NUL CENSE
MBER ,J O V�'p ASPHALT SHINGLES ❑
1
LICENSED CONTRACTORS DECLARATION
I hereby allirm that I am licensed under provisions of Chapter S(commencing with Section WOOD SHAKES ❑
7000)of Dlvlelon 3 of the Business and Professions Code,and my I[cense Is In full force and
effect ( WOOD SHINGLES ❑
License Claes Pf�'1 L((G",1_PNlc.Number
OTHER(SPECIFY) ❑
DateOWNER-cnfmctBUILDER
OWNER the LDER DECLARATION PROPOSED
hereby ,Bu that I am exempt Iro s the e: Any city License Lew for ch the allowing reason.
(Sec.7031.5,Business and Professions Code: Any city or county which Issuance.
also
requires a permit to
construct,alter,improve,to file asiorrepeatany structure,prior to Its l pursuant ole ore quires the BUILT-UP ROOF
applicant for such permit to file a signed statement that he IslicensedSectio pursuant to the provisions
the
of the ss and Contractor's License Lew(Chapter S(commencing with om and 7000)of Division 3 0l the
Business end violation of Code)or that he Is exempt therefrom and the Deese or the alleged ASPHALT SHINGLES ❑
exemption.Any violation cl Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500).):
❑I,as owner of the property,or my employees with wage as their compensation,will do WOOD SHAKES ❑
the work,and the structure to not Intended or offered for sal (Sec.7044,Business and Profes.
sions Code:The Contractor's License Law dose not apply to an owner of property who builds or WOOD SHINGLES •❑
Improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for sale.If,however,the building or Improvement
is sold within one year of completion,the ownernbuifder will have the burden of proving that he did OTHER(SPECIFY) El
build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O. REPORT NO.
apply to an owner of property who bullda or Improves thereon,and who contracts for such projects
with a contractor($)licensed pursuant to the Contractors License Law. PROVp
rMFGR.INSTALLATION SPECS.
'❑I am exempt under Sac. ,B S P.C.for this reason ,
Owner Date P I DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION t ..
I hereby affirm under penalty of perjury one of the fallowing declaration:
❑1 have and will maintain a Certificate of Consent to self-insure for Workers Compensation, �/k z7N'i//P�/ Building
as provae l for by Section 3700 o1 the Labor Code,for the performance of the work or which this L fI
permit Is have and
`~�j'� n 3000�� $
[-] glSfrllC
I have and will the performance
Worker's Compensation which this as required Is
by Section 3700 0l C7
the Leber tion I for the p carrier nee of the work for which this permit Is Isauetl.My Workers
Compansellon Insurance carrier�Policynumber are: � Total
carrier �P� 4io�n n dun 50-y]_ Policy Na, PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NC43
(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 or which this permit is Issued,I shall not employ
any person In any manner so as to become subject to the Workers'CompenSudion Laws of Call. All roofs shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOT CE TO APPLICANT. after makintsbecome
subject to the Workers'Compefnsation provisions of theflcate Leb'orCode,ExemptIu must forthwlith comply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. Sour Y gulations.
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 A OOfc VeringS to Cl i 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 liabilities,
judgments,costs and expenses which may In any way accrue against said City In consequence
of the granting of this permit SIGNATURE O PL DA
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