R 5274 PERMIT. R_ 5274
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 160 DAYS OF PERMIT ISSUANCE OR
. 160 DAYS FROM UST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
E //ff-V(,-)tp4o "r 7T/ YES ❑ iyes—Iunderstand Nat. ClassA
NAME
' A roof assembly is required.
NO Initial I.C.B.O.p
ADDRESS EXISTING ROOF COVERING
PHONE
NUMBER OF EXISTING COVERINGS I
CONTRACT 'S
TO BE REMOVED TO BE RETAINED
NAME i
ADDRESS TYPE OF ROOF COVERING
CITY&ZIPrAISrING
S/jN J o$ a 9'�i/;L_4.
PHONE — BUILT-UP ROOF �l �ypG 4P
LICENSE ' ASPHALTSHINGLES F,p
NUMBER q
LICENSED CONTRACTORS DECLARATION xx
hereby earn that em Business
licensed under Professions
of Chapter 6(commencing with Section WOOD SHAKES ❑ J� '
7000)of Division 3 of Ina Buelneee antl Proleselone Code,and my license le In full torts and
effect. s� _
�//^� ^/ WOOD SHINGLES ❑
License Claes 4& LIC.Number 106 10 6 k
Dale Contractor /_ (` OTHER(SPECIFY) ❑
OWNER.
BUILDERDEC RATION PROPOSED I hereby affirm that I am exempt from the Contractors License Law for the following reason. P A 0
(Sae.7031.6,Business and Professions Code: Any city or county which requires a permit to
conarucLorsuImprove,demoto file signedrepair statement that
prior toItsIssuance,pursuant alsorequlrea one BUILT-UP ROOF ❑ /
of the
eant Cofor such permit a Ills a signed statement nci he Is licensed pursuant to the provisions
the
of the ss and
License Lew(Chapter h(commencing with Section 7000)of Division 3 le the W d La
. ex
Business end violation of Code)or that he Is exempt therefrom and the heels for the applicant
to
ASPHALT SHIN*ES f0
exemption.Any violationof Section 7031r byany applicant for a permit subjects the applicant to of
e dull,as owety not more than five by employees
dollars with
wage WOOD SHAKES r Ur UUr�
❑1,k, owner of me properly,or to ded or oee with wagee as their sole Business
and will s- !T'rAyl,
the work,and the structure Is not intended or offered for sale(Sec.7044,Buelneee entl Profes-
sions
^w
signs Code:The Contractor's License Law does 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 owner-builder will have the burden of proving that he tlM OTHER(SPECIFY) ❑
not build or Improve for purpose of sage.).
❑I,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Profeselons 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 contractions)Ilcensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner oats
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 sell-Insure for Worker's Compensation, /` g� BUlldl
as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which thle l'� '/
permit Is Issued. SgfJ. � $elSrnl
El have and will maintain Worker's Compensation Insurance,as required by Section 3700 of /
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's
Compensatiion1,nwsurence carrier and If number ere:�� S Total
Carrier � /tE l PIONFROMNO� PERMIT AUTHORIZATION DATE
CERTIFICATE EN ATIONI SURANMWORKERS'
COMPENSATION INSURANCE N.C.[:]
(Thos section need not be completed If the permit is for one hundred dollars($100)or leas)
1 certify that In the performance of the work for which this penal a Issued I shall not employ
any person In any manner so as to become subl to the Workers ompansallon Laws of c - All roofs shall be inspected prior to any roofing material being
forma. i stalled. If a roof is installed without first obtaining an
Date f_15 ��J7 Applicant spection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making INS C til a of Exemption,you should bac pn�q.-. A hcant understands and will comply with all non lint
subject to the Workers'Compensation provisions of the Labor Code,you must lorthwlth compl¢'v PP• P Y P
with such provisions or this permit shall be cleared revoked. source regulations.
I certify that I have read this application and state that the above information is correct.)agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof Coverings to be c ss"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
epedla' purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino epelnat liabilities,
judgmanta, .at.
and expenses which may In any way accrue against said City in consequence
. of'gogranungmmispermit. GNATUR F 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