R 5312 PERMIT R_ 5.3 12
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
'
WITHIN DAYS PERMIT ISSUANCE OR
WI DANS F OF
FROM CALLED INSPECTION,
BUILDING ADDRESS Cl"
r
RESIDENTIAL COMMERCIAL OTHER
owNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME LtN'1 roof assembly is required.
J , NO Initial I.C.B.O.#
ADDRESS /0% ,s���rel g /Lel. EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTO
NAME TO BE REMOVED TO BE RETAINED
ADDRESSf TYPE OF ROOF COVERWG Dib
clTvazlP � fS�i� �/ EXISTING DAICDMPEE
PHONE�!` /G d. 6 BUILT-UP ROOF [�j �'f'1997
LICENSE
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter g(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect.
WOOD SHINGLES ❑
License Class Lic.Number -
Date Contractor
OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
1 hereby affirm that I em exempt from the Contractor's License Lew for the following reason.
(Sec.7031,5,Business and Profession$Code: Any city or county which requires a permit to
construct,alter,Improve,demolish,or repair any structure,prior to Its issuance,also requires the BUILT-UP ROOF El
for such permit to file a signed statement that he Is licensed pursuant to the provisions
• o the ss an Professions
License Lew(Chapter B(commencing with omSectionand 7000)of for the 3 of the
exempae entl violation of Code)or that he Is exempt therefrom end the beats for the alleged ASPHALT SHINGLES
exemption.Anyviolationof more
of Section hundred
by any applicant for a permit subjects the applicant to
a civil penalty of not more men flue hundred tlollere with
wage WOOD SHAKES
❑I,as owner of the property,or to employees with wages as their sole compensation,will tl. ❑
the work,and he structure Is not Intended ores not apply
for eels(Sec.7044,Business and builds
o-
Impr Code:TheContractors LicenseLewdoesnotapplytoenowner eproperty who buildsor WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,Improvement that ❑
such Improvements are not completion.
leb n.the
offered mar for sale,ill however,the bulltling or Improvement
Is not ld buildwithinor
provearourposellogihe ownerbulltler will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,as owner of the properly,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who bulltls or Improves thereon,and who contracts for such projects
with a contractor(s licensed pursuant to the Contract 'e icenae Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exam rider Sec. ,B$P.C.for this reason
i
owner_—.-KA 60' - AA-A—Data APPLIC TI E VALUATION PERMIT FEE
ORKER' COMP NSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: VA�pI,�
❑1 have and will maintain a of the
of Consent to sell-insure for Workers Compensation,
this 1p ' /L ��� Building
aeprovitl Is for by Section 3700 olthe Leber Code,for the pedormancaof the work for which this F
r permll is ieeuetl. -r�,
❑I have and will maintain Worker's Compensation Insurance,as requl red by Section 3700 of CITY�ff= Ci I� Seismic
the Labor Code,Mr the performance of the work for which this permit Is issued.My Workers V EH(jry
Compensation Insurance carrier and Policy number are; Total
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N,C.E]
(This section need not be completed If the permit Is for one hundred dollars($100)or lase.)
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'Compeneetlan Laws of Cali. All roots shall be inspected prior to any roofing material being
Ionia, installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
subject to theAPPLICANT.
uk�s'Co paratlonprovialter sionsoftheflcate of LaborrCotle,yoiumustuforthwitbecome
hcomply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. source regulations. 1 ^ �J
I certify that I have read this application and stale 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 chi Brings to be class'C' rbetter
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes. i
(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 consequence I i
at the granting of this permit. .r sIr.1 O�PLICANT 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