R-5373 J APPLICATION FOR CITY OF CUPERTINO PERMIT
u eR R- 5373
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228PERMIT EXPIRES IF WORK IS NOT STARTED
-
WITHIN DAYS PERMIT ISSUANCE OR
WI DANSS FROM LASS T CALLED INSPECTION.
BUILDING ADDRESS
1013 l _
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
VES ❑ If yes—I untlerstand that a Class A
NAME 0., roof assembly is required.
NO Initial I.C.B.O.N
ADDRESS � RQ /�� EXISTING ROOF COVERING
PHONE �5 S —G / / NUMBER OF EXISTING COVERINGS '
CONTRAG S I
r TO BE REMOVED TO BE RETAINED
NAME
ADDRESS U /)�1�J TYPE OF ROOF COVERING
clTv a zI l -7 - �1 SrJ 3 7 EXISTING P A 1
PHONE \�' 77 9f O / 0�
LICENSE BUILT-UP ROOFS�'P 1 j ��+❑
NUMBER �S �� 3 S ASPHALT S t, GLES
LICENSED CONTRACTORS DECLARATION r Uf- L UrCH III
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section - WOOD SHAKES X)"
]000)of Division 3 of the Business and Professions Code,and my license is in lull force and
effect.
WOOD SHINGLES E]License Ci.,Z&L Lie.Number 1575 3 /
Date ' Coil cloy OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION I
PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(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 to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Lew(Chatter 9(commencing with Section]000)of Division 3 of the
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES
a n.Any violation of Section]031.5 by any applicant for a permit subjects the applicant to
civil pej
a civil penalty of net more than floe hundred dollars with
wag.): WOOD SHAKES
❑I,es owner of the property,or tmy eemployeeswith wages as their sole compensation,will do
the work,and the structure is not intended dor oes not for sale(Sea owner
of Business and build.
Pales.
The Conthl does
Lewdoeselftapply toenowner ofproperty who tor WOOD SHINGLES
Improves thereon,and who tloen such work himself or through his own employees,Improvement provided that
such improvements are not completion,
leb n,or offered for seer. ill however,the building or Improvement
n tsold buildhinoneye f ofrpurposetofs le.owner-builder will have the burden of proving that he otl OTHER (SPECIFY)
elft build or improve for purpose of cele.).
❑I,ec owner of the property,and Professions
exclusivelyofssocontracting withContractor's
licensed contractors to construct
the project(Sec. of pr Business andtls or Improv Code:The Contractor's License Lew does not PROVIDE LC.B.O.REPORT NO.
apply to c contractor(s)
property who builds orImprovesthereon,and was contracts for such projects
wuhacontexempt licensed Se pursuant to the Contractor's License Law, PROVIDE MFGR.INSTALLATION SPECS.
❑I em exempt under Sec. ,B 6 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:
El I have and will maintain a Certificate of Consent to Beef-Insure for Worker's Compensation, �] BUlldln
as provided for by Section 3700 of the Labor Code,for the Performance of the work for which this N
p non s Issuetl. - - ! `� 97 Seismic
have end will maintain Worker's Compensation Insurance,as required by Section 3700 of
Ih Labor Coda,lar the pedormance of the work for which this permit Is Issued.My Worker's 1
Compensation In ran carrier end Policy number are: �] ,Q �$vll Total
Carrier �u.. 4 Po�lcy,p.�5 / 7-0 "/� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C. 1
(This section need not be completed If the permit Is for one hundred dollars($100)or less.) L
I certify that In the performance of the work for which this permit Is Issued,I shall not employ
any person in any manner so as to become subject to the Workers'Compensation Laws of Cali. All roofs shall be inspected 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.
subeat to the APPLICANT.
oke es'Co pensaeo provimakinsions of thelcate Laborr Code.you must forthwishould
hbecome
Comply Applicant understands and will comply with all non point
with such provisions or this permit shallibe 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 construction,and All roof Overin sto be lass"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may In any way accrue against said City In consequence SIGNATU OF APPLICANT DATE
of the granting of this permit.
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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
_ OFFICE COPY__ _