R 5156 (2) APPLICATION FOR CITY OF CUPERTINO NUMBER R- 5156
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
'4 d
If �l
L RESIDENTIAL_Ly COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
�
/ YES ❑ If yes—I understand that a Class A
NAME_ .� /b�j,� roof assembly Is required.
NO ❑ B4O
I.C. .N
ADDRESS /l /vim/V/[// �/ /e°4 4�` EXISTING ROOF COVERING
" PHONE D NUMBER OF EXISTING COVERINGS
CONTRACTOR'S s y
TO BE REMOVEDy TO BE RETAINED
NAME
• ADDRESS // //� � (()) TYPE OF ROOF COVERING
CIN 8 ZIP EXISTING
PHONE y —, .,��.'�/��S BUILT-UP ROOFLICENSE
❑
NUMBER ASPHALT SHINGLES ❑ /�
CENSED CONTRACTORS DECLARATION /
I hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES 49
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and C'
effect. WOOD SHINGLES ❑
License Claes
Q Llc.Number
Contractor QQ OTHER(SPECIFY) ❑
OWNER-BUILDERDECARAT16N PROPOSED
I hereby affirm that I em exempt from the Contractor's License Lew 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,prior to its Issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is 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
exemption.Any violation of Section 7031,5 by any applicant for a permit subjects the applicant to
l pp��
a civil of not more then live hundred dollars($500).): v ! �g��
01,as owner of the property,or my employees with wages as their sole compensation,wl11 do WOOD SHAKES
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes-
sions Cne:The Contractors License Lew does not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,provided that .,•V
such Improvements are not Intended or offered for sale.If,however,the building or Improvement
Is sold within one year of completlon,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,em 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.B4O.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 MFGR.INSTALLATION SPECS.
Owneram exempt under Sec. ,B 8 P.C.for this reason
Owner DateA
APPLICATION DATE VALUATION PER
WORKER'S COMPENSATION DECLARATION
hereby and under penalty of perjury one of the Ito self-insure
sure for
Wo D 9 6
❑I have and will maintain a at the
of Consent to eperforma for Worker's Compensation, 1— FI lD (JOp I In
as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which this JU
perm t is
Issued. ( r ,r
have antl will maintain Workers Compensation Insurance,e6 required by Section 3700 0l L „LitIC
th Labor Code,for the performance of the work for which this permit Is Issued.My Worker's V
Compeneatlon Ineurence carrier and Policy nunuler are: Total
Carrier Policy No. PERMIT AUTHORIZATION DATE
<. CERTIFICATE OF EMPTION FROM WORKE S'
COMPENSATION INSURANCE N.C.p
(This section need not be completed If the permit Is for one hundred dollars(5100)or lees.)
I canify that In the performance of the work for which this permit is Issued,I shell not emplay
A any person In any manner co as to become subject to the Workers'Compensation Lews of Call- All roofs shall be inspected prior to any roofing material being
farnl°' installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
subject to thee Workers'CompeTO APPLICANT: nsate n provisionls ofetheficate Of Laborr Code,you must forthwithcomplyApplicant understands and will comply with all non point
with such provisions or this permit sha11 be deemed revoked, source regulations.
I certify that I have read this application and state that the above Information Is correct,l agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof Coverings to be class"C" better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In. /./ ♦ ��
spection purposes. 6
(We)agree to save.Indemnity and keep harmless the City of Cupertino apalnst liabilities,
ohaee which may in any way accrue against said CltyPn consequence
l, e granting of this permit. SIGNATURE OF APPLICANT 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