R-5353 (2) PERMIT R_ 5353
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 �
/6�')���
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
e YES ❑ It yes—I understand that a Class A
NAME root assembly is required.
NO Initial I.C.B.O.N
ADDRES�Sy//7 7^�Z-�� EXISTING ROOF COVERING
` NUMBER OF EXISTING COVERINGS /
CONT ACTOR' ,
TO BE REMOVED TO BE RETAINED
� NAME
ADDRESS / L 2 Com, ���� G(, �i. ✓ TYPE OF ROOF COVERING
d ;?p
clry s ZIP EXISTING
PHONE- 4, � 4Z BUILT-UP ROOF ❑.
LICENSE G ASPHALTSHINGLES
NUMBER CJ O ca CJ O
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter S(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect.
WOOD SHINGLES
License Class Lia Number
Date Contractor OTHER(SPECIFY)
OWNER-BUILDER DECLXRATIONX PROPOSED /
hereby affirm that am exempt from the Contractor's License Law for the following reason. !06
(Sec.construct,
It Business and Professions Code: Any city or county which requires a permit to C
so
o plucant,or suer,ch
Improve,to filedemolish,signed Stany tement that
Is licenseor to issuance,alsore quires the BUILT-UP ROOF
eppllcent for such permit a file a signed statement that g Is licensed pursuant to the provisions3of the
of the ssContractors License Lew(Chapter h(commencing with Section 7000)of for the 3 0l the
Business and violation of Code)or that he Is exempt therefrom and the bests for the applicant to ASPHALT SHINGLES ❑
exemption.Any violation of Section 703 1S by any applicant for a permit subjects the eppllcent to P
e civil penalty of not more than floe y employees
yellers(h Wag): WOOD SHAKES PAID
❑I,as owner of the property,t I to employees with wrepes as their sole compensation,will do ❑
the work,and the structure Is not Intended or offered for sale(Sac.7064,Business end Proles. ,-,Ba !�
dons Code:The Contractor's License Lew does not apply to an owner of property who builds or WOOD SI'Hpl�l ES 3%C ❑
Improves othereon,mts ar who doessuchrworkoffered
r f or sale.11,ho his own employees,or provided that '�Wk- !1[4�
such improvements are not completion,
leb n,or oReretl for leer. ill however,the building o i Improvement n o
Is notsold bull or
prove for purpose of sthe owner-builder will have the burtlen of proving that he did QTHER�(S�I'EEIFY)_
not build as
Improve ler purpose of aefolu U t�11ryt
❑I,ec ownsr of the property,amexolufessions C de:Thewith Contrmees Lice se Lto construct
the protectownerf pr Business and Professions Code:The and who
License Law dosenot PROVIDE LC.B.O.REPORT NO.
apply m an owner of property who builds or Improves thereon,entl who contracts for such protects
with acontexemt under
epurauenttotheContractor'sLicenseLew. PROVIDEMFGR.INSTALLATIONSPECS.
❑I em exempt under Sec. .B 8 P.C.for this reason
Owner APPLICATION DATE VALUATION PERMIT
WORKER'S COMPENSATION DECLARATION
ZFE
I hereby affirm under penalty of perjury one Of the following declaration:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, % Buildin
J
as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which this /� ^�
permits Issued' 7 x o[ Seismic
eve entl will maintain Worker's Compensation Insurance,as required by Section 3700 of
s the r Code,for the performance of the work for which this permit Is Issued.My Worker's - Total
Co pansatlon Ins' 'ce c .ler entl Polley numb re:
Carrier `�C�/r� '�L�? Policy No. .5-71 PERMIT AUTHORI TE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need not be completed If the permit Is for one hundred dollars($100)or lase.)
I certify that In the performance of the work for which thea It Is Issued,I shall not employ
any person In any manner o ae to become subject to gl ComPene t n Laws of Cell- All roofs she a inspected prior to any roofing material being
lornla. installed. If a roof is installed without first obtaining an
oats Applicant inspection,I agree to remove all new materials for inspection.
NOTICE 0 A LICANT: If,after making this Cetlif to of Exemption,you should become Applicant understands and will comply With all non point
subject to the Workers'Compensation provisions of th Lobor Code,you must forthwith comply PP P Y P
with such provisions or this permit sharjoe 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 vertu sto be Cl S"C"Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spectionpurposes.
(We)
(We)agree to ands,expenses
and keep harmless cc City a of Cupertino against liabilities,
ence
/\ of th nes,costa and permit. which may In any way accrue against said City In consequence SIGNATURE OF APPLICANT DAT
of the Br EIngCT 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