R 5709L]
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OFFICE COPY
NUMBER R- 5709
APPLICATION FOR CITY OF CUPERTINO
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
' 1 B DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS -
-
RESIDENTIAL COMMERCIAL --'OTHER—
OVINEFIS
HAZARDOUS FIRE AREA
r )r\ 0 � �
YES [:]If yes - I understand that a Class A '
NAM i f 1 \�M'1
V
roof assembly is required.
NO :;4. . Initial I.C.B.O. #
� EXISTING ROOF COVERING
�'� ✓
ADDRESS—,�
DOREss
NUMBER OF EXISTING COVERINGS
�
PHONE
CONTRACTOR'SO
TBE REMOVED TO BE RETAINED'
NAME rinc
ADDRESS I - S' -
TYPE OF ROOF COVERING „
c1Tv a
EXISTING
PHONE - --�'� ( ' - 1 '' "T'.� V \�
BUILT-UP ROOF 14W
LICENSE - �1
NUMBER (
L—V
ASPHALTSHINGLES El
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B (commencing with Section
WOOD SHAKES ❑
7000) of Division 3 a the Business and Professions Code, and my license Is In full lone and
attest. U
C ���
WOOD SHINGLES ❑
License Class Uc. Number — `
Data ��-(.�-I�^-��_, nry� Q�
Camra
OTHER (SPECIFY)
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OWNER theLDER �/w""�
1! , I�
hereby affirm that am exempt from Co Contractors License Lew for the following reason.
(Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to
PROPOSED
any structure, prior to Its issuance, also the
construct, alter. Improve, demto
BUILT-UP ROOF
file Signed statement
applicant for such permit lila a signed statement that to the
Is licensed pursuant to the pro
�S W
a
of the Contractor's License Lew (Chapter B (commencing with Section 7000) of Division 3 of the
g of the
/
Business and Professions Code) or that he Is exempt therefrom and the basis for the alleged
exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
ASPHALT SHINGLES
a civil penalty of not more than live hundred dollars ($500).):
C] 1, 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 Proles.
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slons 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. however, the or Improvement
of
is sold thinyear of ill
owner-bu)lder will have the burden of proving that he tlld
en pr
OTHER (SPECIFY) ;.
notor for purpose of sthe
nal 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 contractor(s) licensed pursuant to the Contractor's License Law,
PROVIDE MFGR. INSTALLATION SPECS.
❑ 1 am exempt under Sec. ,B & P. C. for this reason
I
Owner Data—
APPLICATION DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑ I have and will maintain a Certificate of Consent to sell -insure for Workers Compensation,
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V.
permit is Is for by Section 3700 of the Labor Cade, for the performance of the work for which this
permit is Issued.
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I /) _
Building/ u+1
6 S
❑ have and will maintain Worker's Compensation Insurance, es required by Section 3700 of
�
-Seismic
_the Labor Cotle, for the performance of the ork for which thio permit is issued. My Worker's
h this
Comp aeon Inst soca carr ntl Policy n bar are:
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Total ic
�
PERMIT AUTHORIZATION
bATE
carr' Pmmy No.
CERTIFICATE,6F EXEMPTION FROM WORKE S'
y --x — _,
hJ\3
/� 3O
CONIEIfin"p r INSURANCE N.C.❑
(This section need not be compl ed"the permit Is for one hundred dollars (E100) or less.)
I certify that In the pedormenca 1 the work for which this permit Is Issued, 1 shall not employ
All roofs shall be inspected prior to any roofing material being
any person In any manner so as to ecome subject to the Workers' Co pensadon Laws or call.
fern)
installed. If a roof is installed without first obtaining an
o e A hcam ) l YJ� Y
inspection, I agree to remove all new materials for inspection.
NOTICE APPLI NT: If, eft r making this Certificate of Exemption, you should became
subject to the Workers' Compensati n provisions of the Labor Code, you must forthwith comply
A Ilcant understands and will comply
PP ply with all non point
with such provisions or this permit s allibe 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 coverings to be class"C"or better.
hereby aphorize representatives of this c\ to enter upon the above-mentioned property for In.
sp purposes.
o ),x I ��
I L 1"'yA11,
(We) save, Indemnify the City
(We) agree Cupertino against liabilities,
entlmay
' vVVl7 n\ a �� 2&1
w wakeep-harmless
s pe inany ai
of the gran costs and expanses which may in any way accrue against said City in consequence
of the granting of this permit.
SIGNATURE OF APPLI A T 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY