R 5842i A
FA
OFFICE COPY
PERMIT R_ 5842
APPLICATION FOR CITY OF CUPE RTINO NUMBER .
REROOF PERMIT - INSPECTION DIVISION - PERMIT EXPIRATION
(408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
1B0 DAYS FROM LAST CALLED INSPECTION.
BUILDINGADDRESS "
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RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
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YES ❑ t yes - I understand that a Class A
NAME _LSU m S 1 p ci
roof assembly is required.
NO _ Initial I.C.B.O. It
So /n
EXISTING ROOF COVERING -
ADDRESS
PHONE -777—,02,0 —7, -
NUMBER OF, EXISTING COVERINGS
TO BE REMOVED 70 BE RETAINED
CONTRACTOR'S /
NAME GTQ A0 S /f OO h G
ADDRESS/��l/Ln/� 1 �m' A`�
TYPE OF ROOF COVERING
CITY 8 ZIP / / / �'J
-7—"
PHONE— 013jr �.4 I�3
BUILT-UP ROOF ❑
LICENSE
NUMBER
ASPHALT SHINGLES
LICENSEDICONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 8 (commencing with Section
WOOD SHAKES ❑
7000) of Divlelon 3 of the Business and Professions Code. and my license to In full force and
effect. Licen9 yl9S3f�4
Cleve Number
WOOD SHINGLES ❑
OTHER (SPECIFY) ❑
Data Contractor
Date
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
PROPOSED
(Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to
'
construct, alter, improve, demolish, or repair any structure, prior to Its Issuance, also requires the
BUILT-UP ROOF ❑
applicant for such permit Ills a signed that licensed to the provisions
of the Contractor's License Lew (Chapter 0 (commencing with Section 7000) of Division 3 of the
a r 9 (commencing
g it 7000) of the
Business and Professlons Code) or that he Is exempt therefrom and the basis for the alleged
ASPHALT SHINGLES
exemption. Any violation of Section 7D31.5 by anyapplicant for a permit subjects the applicant to
a cMI penalty of not more than five hundred dollars ($500).):
❑ I; as owner of the property, or my employees with wages as their sole compensation, will do
WOOD SHAKES ❑
the work, end the structure Is not intended or offered for gale (Sec. 7044, Business and Profen-
al e Cotle: The Contractor's License Law does not apply to an owner of property who builds or -
Improves thereon, and who does such work himself or through his own employees, provided that
'
WOOD SHINGLES ❑
such Improvements are not Intended or offered for sale. If, however, the building or Improvement
Is sold within one year of completion, the owner -builder will have the burden of proving that he did
OTHER (SPECIFY) ❑
not build or Improve for purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct
' the project (Sec. 7044, Business and Professions Code: The Contractor's License Law does not
PROVIDE I.C.B.O. REPORT NO.
apply to an owner of property who builds or Improves thereon, and who contracts for such projects
with a comexempt licensedrSe pursuant to the Contractor's License Lew.
❑ I em exempt under Sac. ,B 8 P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner Date
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION
PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑ l have and will maintain a Certificate of Consent to self -Insure for Workers Compensation,
^_ r m
as provided for by Section 3700 o1 the Labor Cotle, for the performance of the work for which this
"
Buildin�
ml Is Issued.
-/.t,�//q
ave and will maintain Worker's Compensation Insurance, as required by Section 3700 of
lh abor Code, for the the far
-®
T- V ♦ q
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performance of work which this permit is Issued. My Worker's •
ComP;ns Ion Insurance carrlerr a I y are:
jh //Af//1
Yx eW
Q✓ 7V
Total
fiber
`Q Sys
Carrier Iii��CcrA /' W , Policy Nr
/
V
-
,Y]AL.1.$�
P EAR7/ HORIZATION
A
CERTIFICATE OF EXEMPTION FROM WORKERS'
' COMPENSATION INSURANCE N.C.I]
(This section need not be completed If 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
All roofs Shall be In p cted prior to any roofing material being
any person In any manner so as to become subject to the Workers' Compensation Laws of Call.
fornln.
installed. If a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It, akar making this Certificate of Exemption, you should become
subject to the Workem' Compensation provisions of the Labor Code, you must forthwith comply
pp p y non
Applicant understands and will comply with all point
with such provisions or this permit shell be deemed revoked.
Source regulations.
I certify that I have read this application and state that the above Information Is correctI agree
to comply with all city and county ordinances and state laws relating to building construction,and
All roof cow ings to be class "C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
ap purposes.
(We)
(We) agree to save, Indemnity keep harmless
and the City of Cupertino against Ilebllltlea,
jutlgmanle, costs and ;'pensee which may In any way accrue against said City In consequence
01 the granting of this gem lt.
/ !�
SI TUBEE PPLICANT 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