R 5110 PERMIT R_ 5110
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
• 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS `J�-�
RESIDENTIAL ],;�COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
a /�/� YES ❑ If yes-I understand that a Class A
NAME �� • I ' -"' 1 =1 assembly is required.
NO
r ❑ Initial I.C.B.O.N
ADDRESs"'t*"' - (/,� EXISTING ROOF COVERING
t PHONE V NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
` /, TO BE REMOVED�TO BE RETAINED
NAME
ADDRESSRqOF COVERING
-
CITY 8
EXISTING
PHONE BUILT-UP ROOF ❑
LICENSE
NUMBER ASLI SINGLES
LICENSED CONTRACTORS DECLARATION C ✓ /
I hereby affirm that 1 em licensed under provisions of Chapter 8(commencing with Section /yoo'- S KEA O
7000)of Division 3 of the Business and Professlo is Code,and m Ilcsnse Is In full force and 7"
effect.
(' I y l+ WW�SHI S d'Y
Llcenae a Llc.Number N� Y'�i
Det Contractor OTHER(.49f2C1 Y) ❑
NER-BUILDER DE` TION I - PROPOSED O
I hereby affirm that em exempt from the Contractors License Lew for the following re son. .^1
(Sec.70315,Business and demolish,
or rep Code: Any city or county which requires a permit to /
construct,alter,Improve,to file signed statny ement that
prior tnse l pursuant to the provisions
BUILT-UP ROOF ❑
of the
for each permit to flaw a signed statement that he b licensed pursuant to the pro of the
ai the ssContractor's of License Lew(Chapter a(c°mmencinp with omSectionand 7000)of for the 3 of the
. Business and Professions Code)or that he Is exempt therefrom and the bells for the sant to ASPHALT SHINGLES ❑
exemption.Anyviolationnot lonof Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty or not more than floe hundredy employees
dollars with
wag.): � Q
❑I,k,and
er the structure
t not I tended oyeeered wags as(Sec.their 44,ale compeBusinensation,will do WOOD SHAKES
the work,entl the entracte Is not Intended or es not
for sale n ow er of property
es and Proles-
alone
or
Improves
Code;The,an who
LicenseLawtli self or app
through
ployerrywho idedt at WOOD SHINGLES
Improves thereon,entl who tloen such workhimselffor
or.If,how hie own employees,Improvement provided that ❑
luso Improvements are not Completion,
leb n,the
offered for leer. ill however,the en of pr or Improvement
Is not bullld or
prove for purpose
sale.).
Owner•bullderwlll have the burden of proving that he tlltl OTHER(SPECIFY)
❑
not build or Improve for purpaea of saleJ.
❑e,as owner of the property,am exclusively contramina with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who buHda or Improves thereon,and who contracts for such projects
with a contractors)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,8 8 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FE
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to self-insure for Workers Compensation' BUlldln
permit Is Is for by Section 3700 of the Labor Code,for the performance of the work for which rale lOI (�l/tt �O� ��
permit Is Code. I` Ill t4/VArv.
Is
❑ have and will maintain Worker's Camps eetlon Insurance,ee required by Section 3700 0l
a the Leber Cade,for the performance of the rk for whish�ztcce,as req Is d byissued.My 3700rzrof
t e In re ce ser r nd Polity bar are:Paaic iM � " ' 1
PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.I]
(This section need not be completed It the permit Is for one hundred dollars($100)or lees.)
I certify that In the performance of the work for which this permit Is Issued I shall not employ
any person I any manner ea ae m became rub eat to the workers' amps sedan Laws of call. All roofs shall be inspected prior to any roofing material being
f°`nI installed. If a roof is installed without first obtaining an
Date v4Yppllaant inspection,I agree to remove all new materials for inspection.
subject to the Workers. mpef,after nsation provisionas oftheflLaborcate rCode,prion,you should baso a Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked, you must forthwith comply source regulations. p y
Ireply that I have read thisapplicationordinances
state Mat the above Information Is correct, agreeto
hereby authorizy with e
repcity and se county of this cls ane ter upon hela ing tobove- entio ed property
f and All roof coo S to be,CIBSS Or l7 flet.
hereby authorize repraeentetivee of title city to enter upon the above-mentioned property kr Ira by
apection purposes.
(We)
(We)agree to save,expenses
and keep Harmless the City Of i Cupertino against liabilities,
ence
judgments,costa and expenses which may In any way eCCtua against said Clry Inconsequence
. of the granting of this permit. ATURE 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