R-5372 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 5372
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
1B0 DAYS FROM LAST CALLED INSPECTION.
' BUILDING ADDRESS
AA5(.
ESIDENTIAL_X_COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
D - YES [:I If yes—I understand that a Class A
NAME L..Q.,d.0's�.� roof assembly is required.
� �� � NO Initial • I.C.B.O.k
ADDRESS �6 7 6ham'✓ �Oi^ �� 'JI EXISTING ROOF COVERING
PHONE _Q 70 y 7 'O NUMB ER OF EXISTING COVERINGS /
9ONTRACTO�R'$$$'''
NAME TO BE REMOVED TO BE RETAINED
ADDRESV TYPE OF ROOF COVERING
S " C`D ����
CITv&ZIP EXISTING
If U BUILT-UP ROOFLICENSE
❑
NUMBER G G D ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION �y
I hereby affirm that I em licensed under provisions of Chapter 9(commencing with Be OOD SHAKES IJQ '
7000)of Dlvlsfon 3 of the Business and Professions Code,and my license la In full force an %-`
effect. %
/ 3 OOD SHINGLES ❑
License CIQs G� Llc.Number
HER(SPECIFY) ❑
Date Contract p
OWNER.BUILDER DE RATION PR O ED 4I hereby affirm that I am exempt from the Contractors License Law for the following reason. 0
(Sac.7031.5,Business and Professions Code: Any city or county which requlre8 a permit to
construct,alter,improve,demolish,or repair any structure,,prior to Its issuance,also requires the UILT-UP�pO .lA ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions ?
of the Contractor's License Lew(Chapter 9(commencing with Section 7000)of Division 3 of the /� �(`p
• Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ��SP ALT SH NtdLi `W
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the appllcani to v _ /••r,l
a civil penalty of not more than live hundred dollars($500).): /Y
❑I,as owner of the property,or my employees with wages as their sole compensation,will tlo pCD SHAKES lNU ❑
thework,and the structure Is not intended or offered for sale(Sec.7044,Buell a.sntl Profes-
slons Code:The Contractor's License Law does not apply to an owner of property who bullds or W SHINGLES
Improves thereon,and who does such work himself or through his own employees,provltlad Ihat El
such improvements are not Intended or offered for sale.II,however,the building or Improvement / A
is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER (SPECIFY) ❑ �' V
not build or improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sac.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 contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B It 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:
❑I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, Qq j BuiICIIngZ2��
as provided for by Section 3700 of the Labor Cotle,for the performance of the work for which this (�/�./// / !1,373
per�9it is Issued. 7 / / Seismic
;Z I have end will maintain Workers Compensation Insurance,as required by Section 3700 of
e Labor Code,for the performance of the work for which this permit Is Issued.My Workers
Compen n Ins nce carr r antl Policy n mbar err •�, ` ''l/^p Total
Carter Policy No 110_ Y✓/ II/ PERMIT AUTHORIZATION DATE
CERTIFf15ATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.E] l�
(This section need not be completed If the permit Is for one hundred dollars($100)or less.) '
1 certify that In the performance of the work for which this permit is Issued,I shell not employ
any person In any manner so as to become subject to the workers'Compensation Laws of Call. 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.
NOTCE TO ecome
subject 10 the Workere Compens to proANT: It.after visions of thteiLabor Code,s Cerifcate of you mustufo thwlithShoudbcomply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. Source regulations.
1 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 art obe cl S"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
' of the granting of this permit. SIGNATURE F 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