R-5453 APPLICATION FOR CITY OF CUPERTINO
NPERMIUMBER R- 5453
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
.� 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
zml ss RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
�Tj �\ AAS -/ VES ❑ Iiyes—Iunderstandthat. Class
NAMF t�� (�5( �' ✓",l7 1'T O root assembly is understand
that
NO Initial I.C.B.O.#
ADDRESS— I DIM U^'.r.ti Io r s� . 5��� C7Sf/ 7, EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
•� TO BE REMOVED TO BE RETAINED
NAME 144 lo.f �0 I
ADDRESS �..�� 1� TYPE OF ROOF COVERING
CITY&ZIP—1 3\ q. -( �""'�*?:- Sak�esr �S// EXISTING
PHONE r gyg 1 l y1 ' Sam BUILT-UP ROOF
LICENSE
NUMBER —I S Zo/ p ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under Provisions of Chapter 9(commencing with Section WOOD SHAKES ❑
]000)of Division 3 of the Business and Professions Code,and my license Is in full force and
effect' - WOOD SHINGLES
License Clae �� Lic.Num Z ❑ (3/
t OTHER(SPECIFY) PAI 1Q
Date d Contractor
OWNER-Btf ATION PROPOSEDOCT
T
I hereby affirm that I am exempt from the Contrector' Licen ew for the following reason. C I O O
(Sec.')031.5,Business and Professions Code: Any city 0unry which requires a permit to �l rIB
construct,alter,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 ClT
of the Contractor's License Law(Chapter 9(commencing with Section]000)of Division 301 the Y Ulf: Gunk 11
• Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES uU
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil 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,and the structure Is not intended or offered for sale(Sec.7044,Business and Profes-
alone 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 did OTHER(SPECIFY) r
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 contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
r7 am exempt under Sec. ,B&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 Worker's Compensation, BDII
es provided for by Section 3700 of the Labor Code,for the porformance of the work for which this O
parfnll Is Issued. I C7 b/9'�. ��q I �. Seismic _A(2
eve and will maintain Worker's Compensation Insurance,as required by Section Workers
the Labor Code,for the Performance of the work for which this permit le Issued.My Workefs Total
.ma
Insurance carrier and Policy number are:
Carrier JfC- �cl — PolicyN.. 1 ` PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CC
(This section need not be completed if the permit Is for one hundred dollars($100)or less.)
I certify that In the performance of the work for which this permit Is issued,I shall not employ
any person In any manner spas to becomes to the workers'Compensetlon Lawn of Cali- All roof^shall be iTisprected prior to any roofing material being
fornia. 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,after making this Certificate of Exemption,mustforthwithhulbecome
Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code, comply
with such provisions or this permit Shaftbe deemed revoked. 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 construclior and O aclass ette r.
hereby authorize representatives of this city to enter upon the above-mentloned property br in-
spection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costa and expenses which may in any way accrue against said City In consequen'e SI TUR FAP T DA
• of the granting of this permit.
TE I
PRE-INSPECTION: PLYWOOD: -PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY