R 5895 PERMIT R_ 5 8 9 5
APPLICATION FOR CITY of CUPERTINO NUMBER
R-
PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDINGGAADDDRESSSS -
22�SS �( RESIDENTIAL COMMERCIAL OTHER
OWNER'S - HAZARDOUS FIRE AREA
VES ❑ If yes—I understand that a Class A
NAME roof assembly Is required.
/ \ NO ❑ Initial_ I.C.B.O.N
ADDRESS-`dJb I allftO /OSS-
EXISTING ROOF COVERING
PHONE / NUMBER OF EXISTING COVERINGS
CONTRACTO$S
NAME
7 TO BE REMOVED TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
CITUBZIP� ' XE ISTING . f/
PHONE !!5W _ 7S-Ot� BUILT-UP ROOF
LICENSE
NUMBER SZO n ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES El
of Division 3 of the Business and Professions Code,and my license is In lull farce and
stied. WOOD SHINGLES ❑' /
License Cleat Lic.Numb d
Date — Contractor
OTHER(SPECIFY) ❑
OWNER-BUILDS DE LARATI PROPOSED
i hereby affirm that am exempt Irom the Co rest 's Lice a Lew for the following reason. 2•.
(See.7031.5,Business and Protest Cotle: n Ily or unty which requires a permit to T
construct,alter,improve,demolish,or repair any c Stunt,prior to Its Issuance,also requires the BUILT-UP ROOF W�$td El
at
for such permit to file a signed statement that he Is licensed pursuant to the provisions n 4� W�
• of the Contractor's License Law(Chapler 9(commencing with Section 7000)of Division 3 of the ,` (LJE(,
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT MI G S Elexemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to pv�
a civil penalty of not more than five hundred dollars($500).1: v V
E]1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD S�IKEB El
the work,and the structure Is not Intended or offered for Bale(Sec.7044,Business and Proles.
sions Coda:The Contractor's License Lew does not apply to an owner of property who builds or WOOD SHINGLES E)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 did OTHER(SPECIFY) g�.l
not build or Improve for purpose of sale.).
E]1,as owner of the property,am exclusively contracting with licensed contractors to construct ry/
the project(Sec.7044,Business and Professions 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 contractogs)licensed pursuant to the Contractors License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑I em exempt under Sec. ,B B P.C.for this reason
owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
`I hereby affirm under penalty of perjury one of the following declaration:
I�'I have and will maintain a Certificate of Consent to self-Ineum for Workers Compensation, / go Building /y�7
es, r tletl for by Section 3700 of the Labor Code,for the performance of the work for which thio /'_ —�(/,_�� /� UNl^..� g / �
00
permit is Issued. C.C� T f� (.C./ Seismic _� 0
❑ have and will the performance
Worker's Compensation the work
Insurance,permit Is I su Section 3700 0l
.,the Labor Code,for the performance of the work for which this permit le Issued.My Worker's
Compensation nsurenPrrera ���
Total D
Carrier
Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE INC.[]
(This section need not be completed If the permit Is for one hundred dollars($100)or leas.) L9
I certify that in the performance of the work for which this permit Is Issued,I Shall not emptoy
any person in n manner so as to become subject to the Workers'C pengptton Laws of Cell- All roofs shall be inspected prior to any rooting material being
fomla. installed. If a roof is installed without first obtaining an
Date Applieenl inspection,I agree to remove all new materials for inspection.
IC
an
Or
subI tt0 me Works'm Camden ICANT: It,after ovlelo ofeheIn C .. o IS, ecome
yolu must forthwithcomplyApplicant understands and will comply with all non point
with such provisions or this permit shelf; a de ed revs ea. source regulations.
I certify that I have read this appllcatlo state that the above Informa"antion Is correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof coverings t b classor better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
sppurposes.
(We)
(We)ogres to save,penesIndemnify and keep harmless cc City of Cupertino against liabilities,
jutlgmen's
.costs end expenses which may In any way accrue against said City In consequence
."g
f the grammg onme permit. IG ATU E UF 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