R-5210I-
L-1
OFFICE COPY
PERMIT R_ 5 210
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3226 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
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RESIDENTIAL COMMERCIAL OTHER
OWNER'
HAZARDOUS FIRE AREA
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YES E) If yes - I understand that a Class A
NAME 1 ►\lDLAh
roof assembly is required.
NO Initial I.C.B.O.11,
_
3 7 Jlc:�.oll S ���
EXISTING ROOF COVERING
ADDRESS
cV(J-'
NUMBER OF EXISTING COVERINGS '
PHONE
CONTRACTOR'S
/- I
TO BE REMOVED TO BE RETAINED
M
NAME— am, {- ✓�"` Icy Kml �/NLIiC_.
TYPE OF ROOF COVERING
ADDRESS�x
CITY & ZIP 3 �1/'EL�3,�
EXISTING
�/'
PHONE Sy J� 1 - og33
. ❑
BUILT-UP ROOFLICENSE
'NUMBER S
ASPHALT SHINGLES ❑
- LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed untler 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
affect.
WOOD SHINGLES ❑
License Class C_��� 99 Lic. Number
�,(t�` I I tS- M�R/ti
OTHER (SPECIFY) ❑
Data �'J210F1�1�./
r.v"J'
-BUILdor
OWNER -BUILDER DECLARATION
PROPOSED
hereby affirm that I am exempt from the Contractors License Lew for the reason.
Any city or county which requires a permit to
(Sec. 7Business and Professions requires a
Construct, alt ish, or it any prior to its issuance, requirestheBUILT-UP
ROOF
a signed taementrthate, talso otheepr
licant for each permit to lila a signed statement that he is licensed pursuant to the provisions
soplicanelter,improve, to file
of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and the basis for the alleged
ASPHALT SHINGLES
exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than live hundred dollars ($500).):
WOOD SHAKES
1, 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 sale (Sec. 7044, Business and Profes-
sionsCode: The Contractors License Law does not apply to an owner of properly who builds or
WOOD SHINGLES ❑
Improves thereon, and who does such work himself or through his own employees, provided that
such Improvementsare not Intendedplatin, oroffered for sale. however, thebuilding oiimprovement
owner -builder will have the burden of proving that he did
Is itl enof proving
OTHER (SPECIFY)
not build or Improve for purpose of sale.).
notsold bull or prove for purpose of
----'---�
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to construct
the project (Sec. 7044, Business and Professions Code: The Contractor's License Law does not
PROVIDE I.C.B.O. REPORT NO. 2.03 3
apply to an owner of property who builds or Improves thereon, and who contracts for such projects
with a contrectons) licensed pursuant to the Contractor's License Law.
PROVIDE MFGR. INSTALLATION SPECS.
01 am exempt under Sec. ,B & P. C. for this reason
Owner Data
APPLICATION DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
e' A
/
1
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,
(J
Building ,et.uY--(,
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
p rmi is issued.
I have and will maintain Worker's Compensation Insurance, as required by Section 3700 0l
T
��
Seismic Jam, ,
th Labor Code, for the performance of the work for which this permit Is issued, My Worker's
Jy YUh 1 9
ffOPV
Total
Compensation Insurance carrier and Policy number are:
(,
PER TAUTHORIZATION
DATE
Carrier !>,� x/17 Policy No
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
rI
(This section need not be completed If the permit is for one hundred dollars ($100) or lass.)
Co
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 shMIlbe Inspected prior to any roofing material being
forms.
installed. If a roof is installed without first obtaining an
Data Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It, alter making. this Certificate of Exemption, you should become
Applicant understands and will comply with all non point
PP P Y P
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith 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. ) agree
to all cityrep and and
ing toterve-buildingenled
tupon
All r f govering� Class "C" or better
hereby uthoh
property f,
table Of this Cityces to enterthe n-
hereby authorize representatives of Ihis city to enter upon the above-mentioned property for in-
spection
ape purposes.
(Ne) agree to save, Indemnify and keep harmless the City of Cupertino against liabilities,
(We)
A/(__.., //7
A J
judgments, costs and expenses which may In any way accrue against said City in consequence
SIG LURE OF APPLICANT DAT
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