R-5424 APPLICATION FOR CITY OF CUPERTINO
NUMBEPERMIR R- 5424
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
I
W
ML 180
DAYS PERMIT ISSUANCE OR
WDAYSS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
ZZ 1RESIDENTIAL COMMERCIAL OTHER
OWNER'S dd / 1' ,�,/ / HAZARDOUS FIRE AREA
NAME ✓ �( LG tzT.G� //tet�� �'/0� SES ❑ If of assembly is required.and that Class A
Initial I.C.B.O.p
I - 'im (o�� q�l�Ea
/ -�1 EXISTING ROOF COVERING
ADDRESS I�/n `-'v ( `"t I
PHONE NUMBER OF EXISTING COVERINGS I
CONTRACTOR'S
— ( TO BE REMOVED TO BE RETAINED
NAME (4ti 1 e i- oo •c-x ev
ADDRESS ISSS ��� Stx+- . D1Sc. S-�? TYPE OF ROOF COVERING
CITY&ZIP f
EXISTING
PHONE_ I - Sc�c� BUILT-UP ROOF
LICENSE
NUMBER O ASPHALT SHINGLES E]
LICENSED CONTRACTORS DECLARATION �1
I hereby affirm that I am licensed untler provisions of Chapter 9(commencing with Section WOOD SHAKES .A ❑ / V
7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and e" J /
effect. C _
3 WOOD SHINGLE' Q❑ V//
ss Lic.Number F
License Cis p
9
OTHER(SPECIFY) RR� E]Date 2 Contract r - p�
OWNER-BUILDER DEC ATO PROPOSED rC`r-, 4
I hereby firm that I am exempt from the Contractor' Icons aw for the following reason,
(Sec.7031.5,Business and Professions Code: Any city or c unty which requires a permit to Cy7�//ry
construct,after.Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF � ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
' of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the El
and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of not more than five hundred dollars($500).): WOOD SHAKES E]1.as Owner o1 the property,or my employees with wages as their sole compensation,will do ❑
the work•and the structure is not Intended or offered for sale(Sac.7044,Business and Proles.
slons Cada:The Cant there License Law does not apply to an owner of property who builds or
improves thereon,ane who does such work himself or through his own employees,provided SHINGLES ided that El
such improvements are not Intended or Offered for sale.It,however,the building or Improvement t
I...Id 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 Coda: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 contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR. INSTALLATION SPECS.
I am exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
1 have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this 1�� �� �.
permit h Issued. I bb Seismic
ih�have and will maintain Worker's Compensation the workfor Insurance,as required by Section orkers 0,V5-.0'
bor Code,for the performance of the work for which this permit IS Issued.My Workers
Compensation Insurance Lanier and Policy number are: Total
Carrier � Cykd Policy No.�16z�y-9 7� PE UTHORIZATION aD
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.
(This Section need not be completed If the permit Is for one hundred tlollare($100)or less.)
I certify that In the performance of the work for which this permit Is Issued, shell not employ
any person In any manner so atto become eu jaeMlTSfiO'70011tersCompensanon Laws of call- All roofs shall be inspected prior to any roofing material being
torn'.. p installed. If a roof is installed without first obtaining an
Date Z-4 ` Appll m inspection,I agree to remove all new materials for inspection.
subNOecome
,t Eh Workers'C mpereatlonprovleloo. IthelL Io�Cotlemyoumustforthwithbcomply Applicant understands and will comply with all non point
with such provisions or permit shall be deems ea. source regulations.
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 LreOFC veri�gs to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentionetl property for In-
spection purposes.
(We)agree to save,indemnity and keep hsrmiess the City of Cupertino against liabilities, Z
' judgments,costs and expenses which may In any way accrue against said City In consequence f ATU - NT ATE
of the granting of this permit.
PRE-INSPECTION: PLYWOOD: I 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