R-5572•
•
•
OFFICE COPY
PERMIT R- 5572
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
,
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
' IN DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
?N�
/�A
, /
RESIDENTIAL ✓ COMMERCIAL OTHER
OWNERS -
HAZARDOUS FIRE AREA
//'� �����
YES ❑ If yes — I understand that a Class A
NAME A/ &I &Ila
roof assembly Is required,
NO Initial I.C.B.O. N
YL�
IF EXISTING ROOF COVERING
ADDRESS &57_5 -0 2
NUMBER OF EXISTING COVERINGS /
PHONE
CONTRACTOR'S If
L
TO BE REMOVED TO BE RETAINED
NAME JIZ4 AI[ �F�t
TYPE OF ROOF COVERING
�S
ADDRESSl
CITY aZIP_ `i /��;� 2,-7����
EXISTING
/—
PHONE
BUILT-UP ROOF ❑
LICENSE
NUMBER
ASPHALT SHINGLES ❑
LICENSd RACTO
s of Chapter 9 (N
under (commencing calif Section
I hereby that I am licensed under provisions of Chapter
WOOD SHAKES
iaffirmnion
]000) of Division 3 of the Business and Professions Code, and my license is In full lona and
y
affect.
WOOD SHINGLES ❑
License Class Lic. Number
OTHER (SPECIFY) ❑
Dale Contractor
PROPOSED d
OWNER BUILDER DECLARATION
I hereby affirm that am exempt from the Contractor's License Lew for the fallowing reason.
(Sec. ]0315u, Business and Professions Code: Any city or county which requires e permit to
or rep anystructure, prior to its issuance, the
construct, alter, Improve, demto
BUILT-UP ROOF ❑
file signed stir
to theprovirequires
applicant for such permit .o file a signed statement that is licensed pursuant m the provisions
the
of the Contractors License Law (Chapter a (commencing with Section ]000) of for the 3 of the
g
Business and Professions Code) or thet he is exempt therefrom and the bads for the alleged
ASPHALT SHINGLES
exemption Anyviolationo of Section by any applicant for a permit subjects the eppllcent to
nve]0315
pen.
t more ):
a civil penalty of not more than five hundred dollars (h
WOOD SHAKES ❑
employees with wages as their sole compensation, will do
❑ I, as owner of the property, or wag
to for sale (sea Business entl Porwilds
the work, and the structure is not intended ores
or
Bions Coda: The Contractor's License Lew does not owner of
apply to an owner o property who builds or
WOOD SHINGLES ❑
elf provided that
thereon, and who does such work himself or through his own employees,
such improvements offered for sale. however, building or Improvement
such improve mens aro net intended Improvement
btheur
ill
Is sold the Owner-builderwill havetheburdenof proving that he did
OTHER (SPECIFY) ❑
or
not builtl or Improve for purpose of eels.).
not prove for purpose of
I, as owner of the property, em exclusively contracting with licensed contractors to construct
the project (Sec. 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 fill INSTALLATION SPECS.
1 am exempt under Sec. ,B 8 P. C. for this reason
Owner Date
APPLICATI ATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I
Fp
I hereby affirm under penalty of perjury one of the following declaration:
1 haver and will maintain a Certificate of Consent to sell -insure for Workers Compensation,
l
�' 1Q
Buildin
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
Issued.
l
7y
gyp.
MIs
RLhave antl will maintain Workers Compensation Insurance, as required by Sectlon 3700 of
v% -'CCr/j
/ q J /OQ
Seismic
1h4 Labboor Code, for the performance of the work for which this permit is Issued. My Workers
L(/ V
Compensation Insurance Policy�/
�`2y�
Total
carrier entl mbar are:
�,
PERMITAUTHORIZATION
DATE
��
Carrierr��!(i4�( Policy No.4�1
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ
(This section need not be completed If the permit Is for one hundred dollars ($100) or less.)
I certity.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 s -all M Inspected prior to any roofing m terial being
fornia.
installed. If a roof is installed without first obtaining an
Data Applicant
inspection, I agree to remove all new materials for inspection.
Applicant understands and will comply with all non point
Exemot
NOT CE TO APPLICANT: shoul
after sion�s lLabor yolu
musOf
subject Io the Workers' Compensation provIf,
ofethe Code, fo thwlthbecome 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.I agree
to comply with all city and county ordinances and state laws relating to building construction, and
All roof coverings to be class " o better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes.
(We) agree .o 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
SIGN TURF F PPLIC DA
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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY