R-5606 PERMIT
APPLICATION FOR CITY of CUPERTINO NUMBERR_ 5606
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
' 100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS(� T /y
/6 evyo �/ �" l-ee, RESIDENTIA COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
—,� YES ❑ If yes—I understand that a Class A
NAME y 'C�_p� ,f� oof assembly is required.
L_ N� Initial I.C.B.O.#
ADDRESS���3C7 �_/�"P EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
�ONTR TOR
//�r / TO BE REMOVED �! TO BE RETAINED
NAME
ADDRESS r �J TYPE OF ROOF COVERING
CIN 8 zip_OnS`S?{
�l r7 EXISTING
PHONE BUILT-UP BUILT-UP ROOF ❑
LICENSE / /_ ASPHALT SHINGLES ❑
NUMBER r/
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensetl under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
nea
. t.
WOOD SHINGLES ❑
License Class ` _ Lic.Number
OTHER(SPECIFY) ❑
Date Comm
OWNER-BUILDER DECLARATION iiPROPOSED
I hereby affirm that 1 am exempt from Co e: Any city License Law for the following reason.
cons.70315,Business and demolish,
or rep Code: Any city or county which requires also a permit to
construct.alter,Improve,to file signed
n dstaair eny mentructure,that he prior tolls Issuance,to
he provisions
of
BUILT-UP ROOF ❑
of the Contractor's
such permit to file a signed statement that he IslicensedSectio pursuant to the provisions
of the Contracture Usions Law(Chapter 9(commencing with$salon 7000)of Division 3 of the
• Business and Professions Code)or thet he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES
a n.Any violation of healon 7031.8 by any applicant for a permit subjects the applicant to
civil pe
a civil penalty of not more than five hundred
employees
yeesdollars(h wag):
❑I,as and
the structure
pre is n t i tended oyeeered for
(as Sec.their sola compensation,will do WOOD SHAKES ❑
the work,entl the structure Is not intended ores not for eels(Sea owner
of Business and builds
s-
ImprCotle:The,antmc.o d Licence Lew does not apply toanowner ofproperty whobuildsor WOOD SHINGLES ❑
Improves thereon,entl who does such work offered
oil or Through his own employees,or Improvement provided that
such Improvements withinonyeare not intended or owner for sale.illf.however,the en of pr o i Improvement
Issoldor
prove for purpose of
owner-builder will have the burden of proving that he did OTHER(SPECIFY) - ❑
not bulitl or Improve Mr purpose of eeleJ. _
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sea 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 -t
with a contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Date APRI19A110 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 Ball-Insure for Worker's Compensation, MAY Ory RXV
Building
as provided for ection 3700 of the Labor Code,for the performance of the work for which this //99 FrQ
permit is
ave entl will maintain Worker's Compensation Insurance,es required by Section 3700 o1 C1 p�/� $el$mIC
Iha abor Cotle,for the performance of.he work for wMCM1 this permit Is Issued.My Workers u} �UYEh f'LYV Total
Compensation Insurance carrier andPolicynumb ere:
IS
Carrier �✓ , ``1QE'� PollcyNo.
� PERMIT AUTHORIZATION DATE
CERTIFICATE EN EXEMPTION FROM WO E S'
COMPENSATION If the ON INSURANCE N.C.❑
(This section need not be completed If the permit Is for one hundred doller9($100)or less.)
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.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and will I with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP comply Y P
with such provisions or this permit shall be deemed revoked. Source regulations.
I certify Nat I have read this application and state that the above information is correct.I agree
to comply with all city and county ordinances and slate laws relating to building construction,and All roofcovenngs to be
class/"CC"/or better.
hereby authorize representatives of this coy to enter upon the above-mentioned property for in. � f
reon purposes. 2
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities,
judgments.costs and expenses which may in any way accrue against said City in consequence SIGNATURE-CIF A LICA 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY