R-5472 (2) PERMIT
• APPLICATION FOR CITY OF CUPERTINO NUMBERR_ 5472
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
I
W
All
THIN DAYS PERMIT ISSUANCE OR
WDANSS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
/ / '-1 L/ &5�9462 toe,
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ It yes-I understand that a Class A
NAME roof assembly is required.
N Initial I.C.B.O.If
ADDRESS - ��7���"� `-'��(� EXISTING ROOF COVERING
PHONE �S Z '�1 J NUMBER OF EXISTING COVERINGS ,
CONTRACTOR'
Z2 1P TO BE REMOVED TO BE RETAINED
NAME
ADDRESS �1�� TY F ROOF OVERIN • r.
CITY&ZIP o`- L, EXISTING
��0� ��l
PHONE BUILT-UP ROOF ❑
LICENSE —— .'J 6 ASPHALT SHINGLES ❑
NUMBER !y
LICENSED CONTRACTORS DECLARATION
hereby affirm that 1 am Business
n ss under Professions
loss of Chapter B(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business antl Pro/acetone Cotle,and my license Is In lull force and
effect. // WOOD SHINGLES ❑
License Cl 20 Contrr Number S b OTHER(SPECIFY)
❑
Date `- COOtraCtOr
OWNERBUILDER DECIARATI9 PROPOSED
I hereby affirm that I am exempt from the Contractor's Lic se 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,prior to Its issuance,also requires the BUILT-UP ROOF 0
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions R1�
of the Contractor's License Law(Chapter B(commencing with Section 7000)of Division 3 of the N O n
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT$HING12Fy ,O
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500).): WOOD SHAKES
❑I,as owner of the property,or my employees with wages as their sole compensation,will do Nr
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes. ///r
slons Cotle:The Cant motors License Law 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
such improvements are not Intended or offered for sale.If,however,the building or Improvement / /Ile b
is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY)
l.•
not build or Improve for purpose of said.).
❑h as owner of the property,am exclusively contracting with licensed contractors to construct
the project(See.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT N
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractions)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR. INSTALLATION SPECS.
❑1 am exempt under Seo. ,B&P.C.for this reason
Owner Dale APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: �e
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, / Pr Building
as providetl for by Section 3700 of the Labor Code,Mr the performance of the work for which this /O ^ Cr/ 1
p rm1 issuatl. Co/7 / 5 $eISR11C
have antl will maintain Worker's Compensation Insurance,ee required by Section 3]00 of ! /
th .e sr Code,for the performance of the work for which this permit Is Issued.My Workers
Compensation Incur nca ml er e d Policy number are: Total
7
Carrier a W- I Policy NoA�L'`S_lJ-/5ZZ PERMIT AUTHORIZATION ATE
CERTIFICATE OF EXEMPTION FROM WORKERS' ^`
COMPENSATION INSURANCE N.C.p V
(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 Ia any neer a ee to become subea t 1 e wor compeneanon Laws of Call. All roofs shall be inspected prior to any roofing material being
fornla. / installed. If a roof is installed without first obtaining an
Date /0 � v Applicant aett inspection,I agree to remove all new materials for inspection.
NOTICE subject to theOWorrkerldAl after s'Compensation making
ro isionie ftthelffibar Code,of you mustforthwishould
thbecome
comply Applicant understands and will comply with all non point
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 comply with all city and county ordinances and state laws relating to building construction,and All roof cov in obe class"C"or better.
hereby authorize representatives of this city to anter upon the above-mentioned property for In. ') p
sp(We) purposes. - w �� /
(We)agree to save,expenses
w and keep harmless the City of Cupertino against llabllitlas, //
• lutlgments,costa and expenses which may In any way accrue against sem Cl ly In consequence SIGNATURE 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY