R-5389 (2) ' APPLICATION FOR CITY OF CUPERTINO NUMBI R R 5389
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
' 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
x613b7 cP
RESIDENTIAL � COMMERCIAL OTHER
OWNER'S - HAZARDOUS FIRE AREA
YES ❑ It yes-I understand that a ClassA
NAME roof assembly is required.
NO Initial I.C.B.O.k
ADDRESS Sa �i EXISTING ROOF COVERING
PHONE 7 NUMBER OF EXISTING COVERINGS I
CONTRACT
TO BE REMOVED / TO BE RETAINED
NAME ^a�+�Q-9-�
ADDRESS 95/0 ' )t a /� � _ TYPE OF ROOF COVERING
aTv s zIP l-� I. I,i.� � EXISTING
r� `7-0
Ga .
PHONE / 7 ! ��7�7� 1 BUILT-UP ROOF ❑
LICENSE S/ ASPHALTSHINGLES� /
NUMBER 7'
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES v
7000)of Division 3 of the Business end Professions Code,and my license is In full force and
affect. 1'�f�
f
S WOOD SHINGLES
License Class Lid.Number
Date
/O OTHER(SPECIFY) OC]' 21
Contractor yp
OWNER-BUILDER DECLARATIO C��'b I/
hereby affirm that am exempt from the Contractors License Law for the following reason. PROPOSED I (J�: `.upk
(Sec.7031.5,Business and Professions Code; Any city or county which requires a permit to H NO
construct,alter,improve,demolish,or repair any stmcture,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 she 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 she alleged ASPHALT SHINGLES
exemption.Any violation el Section hundred
by any applicant for a permit subjects the applicant to
e civil penalty of not more man five hundred yellers(h wag): WOOD SHAKES ❑
❑I,es owner oftru property,or to dedemployeaswith wages astheir sole compensation.will s.
she work,and the Contractor's
is not intended or offered for sale n ow er of Business and Proles-
sions Cade:The Contractor's License Law does not apply to an owner of property who buildsor WOOD SHINGLES ❑
improves thereon,and who does such work himself or through his own employees,provided
d tshat
such Improvements are not Intendedn,or ownetlforsale.I(however,the building oiimprovement
e did
not sold bull ori provyear ofmmpletof sal eowner-0uiltlerwill have the burden ol provingthashetlitl OTHER(SPECIFY) ❑
not builtl 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 Lew does 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 s contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
I am exempt under Sec. ,B&P.C.far this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
hereby affirm under penalty of perjury one of she following duce for Wo ``
❑ have and will maintain a of thei Lab of Consent to performance
for Worker',Compensation. BUIIdI
as mit its is for by Section 370001 the Labor Code,forme pedormance of the work for which this
palmll is issued.
and
❑I have will maintain performance
Workers f the work
for Insurance,as permit Is d by d.My Works of 101"2-1/7 ,7 /`�/ L!Ulf Seismi
the Labor Coda,for she pedormance of she work for which this permit Is Issued.My Worker's '
.the
pIns�urance carr^ie'rl and Policy number are: '7 Total
Carder I 5 / �� �3 PolicyN M Tf'`� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.
(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 amploy
any person In any manner so as to become subject W Orkem'Comp ,atlon Laws of call- All roof^shall be inspected prior to any roofing mat rial being
forme./C7 installed. If a roof is installed without first obtaining an
Date Y 9 Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It,after making this Cerci' to of Exemption,you should become Applicant understands and WIII comply with all non point
subject b the Workers'Compensation provisions of 8 e Labor Code,you must forthwith comply pp p y p
with such provisions or this permit shalfjbe deemed revoked, Source regulations.
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,and All roof coversto be cass"C"or better.
hereby authorize representatives of this city t0 enter upon the above-mentioned property for In-
spection purposes.
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities,
' judgments,casts and expenses which may In any way accrue against said City in consequence SIGNATURE OF APPLICANT DATE
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 '