R 5772 PERMIT R_ 5772
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
180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS ,
v' ��Ir 64P.-J,
[ , `
{ �6 .-J, RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
wAnCh' A/� YES EJIf yes—I understand that a Class A
NAME_ �v r'_ `I L� roof assembly is required,
.NO ❑ Initial I.C.B.O.N
ADDRESS • / p y EXISTING ROOF COVERING
� (j O
PHONE L ( O 0 NUMBER OF EXISTING COVERINGS
CONTRACTOAR'S�,�.,. n�,,� /
NAME MItKi I IC{F��i TO BE REMOVED TO BE RETAINED
ADDRESSi� QJTYPE OF ROOF COVERING
CITY 8 ZIP Y1 y S 04^tC6j�5�,d!11p
EXISTING
PHONE BUILT-UP ROOF ❑
NUMBER T ���� ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES I[Ji
7000)of Division 3 of the Business and Professions Code,and my license It in full force and
exact. �j (Se—Z WOOD SHINGLES ❑
License Class/y. Lie.Number
Data G^/ g contractor Nr/�fl OTHER(SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,alter.Improve,demolish,or repair any structure,prier to Its Issuance,also requires the BUILT-UP ROOF ❑
applicant for Ruch permit to file a signed statement that he la licensed pursuant to the provisions
of the Contractors License Law(Chapter a(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 LrJ
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of not more than five hundred dollars($500).):
C] H
WOOD SAKES
I,as owner of the property,or my employees with wages es their safe compensation,will do ❑
the work,and the structure is not Intended or offered for tele(Sec.7044,Business and Profes-
slonsCode:The Contractors License Lew does not apply to an owner of property who bulks or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,provided that .❑
such Improvements are not Intended or offered for sale.It,however,the bullding or Improvement
Is sold within one year of completion,the owner-builder will have the bu rden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who bulltls or Improves thereon,and who contracts for such projects
with a contractor(,)licensed pursuant to the Contractor'$License Law, PROVIDE MFGR.INSTALLATION SPECS.
C)I am exempt under Sec. ,B 8 P.C.for this reason-
owner APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: / (J
❑I have and will maintain a Certificate of Consent to sell-Insure for Workers Compensation, CO ¢O Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this o O !1 g
permit Is Issued. Seismic
❑ have end will the performance
Worker's Compensation the wokfor Insurance,as requlmtlsu Section 3700'of s
the Labor Code,for the performance of the work for which this permit to Issued.My Worker's 1 ''7
Compensation Insurance carrier and Policy number are: $D Total ( v
Carrier Policy No. PERMIT ATHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
(This section need not be com0 ed ICOMPEI,he perATIONmNst forr oneEhundred dollars($N 0))oor lose.) t'.I Ur VOr Lft t
0-6 fF
I cedlly that In the performance of the work for which this permit Is Issued,I shell not employ C
any person In any manner so as to become subject to the Workers'Compensellon Laws of Cao- All roofs shall be inspected prior to any roofing material being
ferule, installed. If a roof is installed without first obtaining an
Date ^/ Applicant � a� inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,alter mal,1 hie Certificate of Exemption a e a Applicant understands and will comply with all non
subject to the Workars'Compensation previsions of the Labor Code,you mus ort whh comply pP' p y point
with such provisions or this permit shall be deemed revoked. source regulations. -
I certify that l have read this application and state that the above Information Is correct,l agree
to comply with ail city and county ordinances and state laws relating to building construction,and All roof coverings to be class or better.
hereby authorize representatives of this city to anter upon the above-mentioned property for in.specti /J — �}yA
judgments,
n purposes. C/,�( /_ /—/ 0
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, /jam
of the gran coats and expenses which may In any way accrue against said Clty In consequence
. of the granting of this permit. GNAY`IT�OF�S�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