R-5223 (2) PERMIT
'APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 5223
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 WITHIN
FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S _ HAZARDOUS FIRE AREA
/p� / VES Ll yes-I understand that a Class A
NAME `{!1.�'f�/� root assembly is required.
c� // _/� � NO ❑ Initial I.C.B.O.p
ADDRESS 5 -07 S_b `Aer✓/�C�l'/-/'�'/-'TP,r-`�, EXISTING ROOF COVERING
PHONE O NUMBER OF EXISTING COVERINGS
CONTRACTO
/� �5 I �OD�G�✓J TO BE REMOVED TO BE RETAINED
.NAME
ADDRESSTYPE OF ROOF COVERING
e CITY&ZIP/(9 rSS � ii D. ��/ �'y-CA�w,�.,�
EXISTI
t-.CAR� ExlsTl
NG
PHONE- 2.S- BUILT-UP ROOFLICENSE
❑
' NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION Is\n ^
I hereby affirm that I em licensed under provisions of Chapter B(commencing w WOOD SHAKES M J �Q1D
7000)of Division 3 of the Business and Professions Code,and my license is In fu too e
offset. ! ❑ 10 �
j� WOOD SHINGLES r\r3 9 �f
License Class 1' -3 Q Lo.Number !(57j � w� ,gad` �O
HER (SPECIFY) N\y ^�0�1
Data -BUILDS ada
OWNER BUILDER DECLARATION n A
OPOSED
hereby affirm that am exempt from the Contractor's License Lew for the bitewing reason.
(Sec.70315,r,improve,
and Professions Code: Any city or county which requires a permit to Y�J ``
construct,eller,improve,tlemclisR or repair any structure,prior ro its issuance,also requires the BUILT-UP ROOF 64
applicant for such permit to flle a signed statement that he Is licensed pursuant to the provisions
of the ss and Pro License Lew)or that h(commencing with Section and 7000)of for ionthe 3 of the
Business end Professions Code)or that he Is exempt therefrom end the baste for the applicant
to ASPHALT SHINGLES
exemption.Anyviolationo t more
o Section 7031.5 by any applicant for a permit subjects the applicant to /^
e civil penalty of not mere than live by dredempl yee$ th wage: WOOD SHAKES
`!
❑I,as owner of the property,or to amployeee with wages as their 7 44,compensation,will s- ❑_)
the work,and the structure is not Intended or offered for sale n owner
of property
and Profes-
sions Code: The Contractor's license Low does not apply to an owner of property who builds or WOOD SHINGLES ❑
Improves thereon,and'who does n such work himself or through his own employees,Improvement provided that
such Improvements ars not platin,oroffered for Bale.It,ill however,thebuildingof pros Improvement
notsold bull or
prove arclompletof sale.).Owner-builder have the burden of proving that he do OTHER(SPECIFY)
not build or Improve for purpose of sale.).
❑1.as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Cade:The Contractors License Law does not PROVIDE I.C.B.O. REPOR N
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractors)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
I em exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
11 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, '/p(as o Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this N4 0
permit is Issued. G
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of i(/ q (J Seismic ` d V
r the Labor Code,for the performance of the work for which this permit is Issued.My Workers `
Total
Compensation Insurance carrier and Policy number are:
Carder. �--_-- //? l�/�// �Iicy No. PERMIT AUTHORIZATION DATE
CEmIFICA %EMP ION FROM WORKERS'
COMPENSATION INSURANCE N.C.p
(This section need not be completed If the permit Is for one hundred dollars($100)or less.)
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 Cell- All roofs shall be inspected prior to any r o ing material being
Iornia. // installed. If a roof is installed without first obtaining an
Datg�_7Applicant /ice illinspection,I agree to remove all new materials for inspection.
subject othe
6666WAAAAorkereCCom:pensalaftonprovisionsofthemakintis CelLabor Code,of you/m`usstuf`orthwltthhbecome comply Applicant understands and will comply with all non point
with such provisions or this permit shalQbe deemed revoked. source regulations.
1 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 rotating to building construction,and All roof coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property or in-
spection purposes.
(We)agree to save.Indemnify and keep harmless the City of Cupertino against liabilities,
' judgments, and e
costs expenses which may In any way accrue against said City In consequence
of the granting is thisand 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY