R-5294•
OFFICE COPY
PERMIT
5294
APPLICATION FOR CITY OF CUPERTINO NUMBERR_
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
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RESIDENTI - COMMERCIAL OTHER
OWNER'SHAZARDOUS
FIRE AREA
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9
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YES L' If yes— I understand that a Class A
NAME 1' ` U / LLQ
roof assembly is required
NO ❑ Initial I.C.B.O. k
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a),I`JO 6QA JUan
EXISTING ROOF COMERINQ
ADDRE4R
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-`a'5 ` 0076
NUMBER OF EXISTING_QQVERINGS '
PHONE .
CONTRACTOR'S��
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5ea5-mns
Roo-��►a
TO BE REMOVED I TO BE RETAINED
NAME
ADDRESSn
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TYPE OF ROOF COVERING
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EXI T IN
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PHONE 1� a
BUILT-UP ROOF _ ❑
LICENSE r
51
NUMBER 1XI,�
ASPHALTSHINGLES ❑„
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with Sej lIon
WOOD SHAKES
]000) of Division 3 of the Business and Professions Code, and my license is in full force and
effect' - �'
WOOD SHINGLES ❑
Lic. Number i
License las�yI0177
OTHER (SPECIFY) ❑
�,DateContractor
LP—L:�r
OWNER -BUILDER DECLARATION
PROPOSED
I hereby affirm that I am exempt from the Contractors License Law for the followin seen.
(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 lts�lasuance, also requires the
BUILT-UP ROOF 1�.�
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
❑
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Business and Professions Code) or that he is exempt therefrom and the basis for the alleged
ASPHALT SHINGLES O
exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of net more than five hundred dollars ($500).):
01, as owner of the property, or my employees with wages as their sole compensation, will do
WOOD SHAKES X
❑�^'� j
the work, and the structure is not Intended ore for sale (Sec Business and Proles-
' /
cions Code: The, License Law does not apply to owner of property whoidedk or
_ I
WOOD SHINGLES - 01N1 / p '�11
❑
an who elf or hisO Own
improves e en, and who does such workhimselff oil ar through his own employees, provided t
es,
not Intended orofferedbarsale, however, thebuilding Improvement
suchImprovementswithin
p..� II
Is Id one year ill enof pros
owner -builder will have the burden of proving that he did
OTHER (SPECIFY) U,V
ntbuildo Improve for purposcompletion, fsilia
not bulltl ar 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 contractors) licensed pursuant to the Contractor's License Lew,
PROVIDE MFGR. INSTALLATION SPECS.
[] I am exempt under Sec. ,B & R C. for this reason
Owner Date
APPLICATION DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
A,,
�
Building / 71"
I hereby affirm under penalty of perjury one of the following declaration:,
I have and will maintain a Certificate of Consent to self -insure for Worker's Compensation,
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
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permit Is Issued.
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"II have and will maintain Workers Compensation Insurance, as required by Section 3700 of
Seismic
the Labor Code, for the performance of the work for which this permit Is Issued. My Worker's
/ 9
Comp tion Insure a carr n Policy fid er are: I ��
Total 3d
PERMIT AUTHORIZATION
DATE
Carrier Polley No.
-I CERTIFICATE OF EXEMP ION FROM WORKERS'
not, N.C.[
(This section need not be completed it the permit Is for one hundred dollars ($100) or Iess.)
I certify that in the performance of the work for which this permit Is Issued, I shall not employ
All roofs Shall be inspected prior to any roofing material being
any person in any manner so as to become subject tote WorkersCompensation Laws of Cali-
fornia.
installed. If a roof is installed without first obtaining an
installed.
Date 4�4-a.� Applicant
I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: II, after making this Certificate of Exempuo ou should become
to the Workers' Compensation Labor Code, forthwith
Applicant understands and will comply with all non Dint
PP P Y P
subject provisions of the you at comply
with such provisions or this permit shall be deemed revoked.
source regulations. -
I certify that I have read this application and state that the above Information is correct. ) agree
to comply with all city and county ordinances and state laws relating to building construction, and
All rO oBrings to eclass "C"or better.
hereby authorize representatives of this city to enter upon the above mentioned property for In.
'
speedo) agree to
(We) agree to save, and keep harmless the City Cupertino against liabilities,lence
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judgments, expenses ai
ry costs and expenses which may in any way accrue against said City in consequence
SIGNATURE OF APPLIC DATE
the gran
of the granting of this permit.
PRE -INSPECTION:
PLYWOOD:
IN-PROGR
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