R-5536 PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 5536
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/ /
10-5-71g� RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
��i/ �2S YES ❑ If yes-1 understand that a Class A
NAME G� roof assembly Is required
�p NO E] Initial I.C.B.O.k
ADDRESS 10571 S7Z)�d 4/� � EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS0�/ p _� c ,y s 9�3 p TYPE OF ROOF COVERING��
clTvazIP ^SFJ ,/' EXISTING 3
PHONE � 7??-8 33J BUILT-UP ROOFLICENSE ❑Q
5
NUMBER S9" ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION (+
1 hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES 6 A p.
7000)of Division 3 of the Business and Professions Code,and my license la In lull force and Cff �f
effect' WOOD SHINGLES Y
License Class `—� Lic.Nu er L
Date�+ Contrec OTHER(SPECIFY)
OWNER-BUILDERD RATION PROPOSED
I hereby affirm that I am exempt from th rector's License Law for the following reason. AUG 2 6 7997
(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 Its issuance,also requires me BUILT-UP ROOF ❑ '
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions BLDG. IN.
of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Divlsion 3 Of the INSPECTION
Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES IbPARTfNENT
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to 'VII Y OF CUP R❑TINO
a civil penalty of not more than five hundred dollars($500).8 WOOD SHAKES E
❑I,as owner of the property,or my employees with wages as their sole compensation,will do
the work,and the structure Is not intended or offered for satth
So.7044,Business and Profes.
Bions Code:The Contractor's License Law does not apply towns (property who builds or WOOD SHINGLES ❑
Improves thereon,and who does such work himVdde
rous ow mp) ees,provided that 'An
such improvements are not intended or offeredIl,hver, ding or Improvement / rol
Issold within one year olwmpletlon,the ownerilih enolprovingrhal he ditl OTHER(SPECIFY)not build or Improve lot purpose of sale.). �G-1
❑I,as owner of the property,am exclusivelyngicensed contractors to construct
the prolect(Sec.7044,Business antl Professio Thntractor's License Lawdoes 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 contractogs)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B a P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declaration: ..
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Building 1!"i
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this p �f
permit is Issued. -.� / Seismic
❑ have and will the performance
Worker's Compensation Insurance,as required by Section 37de of /"t,7 ` /
Co Labor Code,for the performance of the work for which this permit is Issued.My Worker's Total /�
Compensation Insurance carrier and Policy number are m.� apt?�l(�
Carrier.� � 7 Policy No.2 � PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑ A. ^ O (zlf I� j tl�
(Chia fy that
need not be oncecompletedthe
if the permit is for one huntlIS I ...Idollara($10shall not
lasso � � (L 1/ f a 61
certify that In the performance of the work for which t s permit Is Issued, shell not employ
any person in any manner so as to become subject to the orkers'compareauon Laws of call- All roofs shall be inspected prior to any roofing material being
forms. 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 Car ficate of Exemption,you should become Applicant understands and will comply with all non dint
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP P Y P
with such provisions or this permit shall be deemed revoked. source re nS.
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,antl All �coveri Stoto C /-C"or better.
hereby authorize representatives of this city to enter upon the above-menllonetl property for in-
spection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, O
judgments,costs and expenses which may in any way accrue against sold City In consequence >afIXTUREOF APPLIC DATE
. of the granting of this permit.
PRE-INSPECTION: PLYWOOD: IN-PR ESS:
INSP.-DATE INSP. DATE - INS . DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE INSP. DATE INSP. DATE
2s=y NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY