R-5674 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R� 5674
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
•
WITHIN LBO DAYS OF PERMIT ISSUANCE OR
WI180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
C) r7 ,q I 1--A R/4 L-L- c))4E 1 21 �
Cts PE FLT I a0 �� {JD I k�4 RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
(/�\ YES ❑ If yes-I understand that a Class A
NAME—A` LL[/,/ V wit I b A roof assembly Is required.
/ NO ❑ Initial I.C.B.O.e
ADDRESS—/O 7'. I T-14 1Z ti Nla` (� EXISTING ROOF COVERING
PHONE Pe�11-77/t NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAME
AQDRESS TYPE OF ROOF COVERING
CI &ZIP
EXISTING
PHONE BUILT-UP ROOF ❑
LICENSE
NUMBER - ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES g
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and -
affect' WOOD SHINGLES ❑
License Class Lic.Number
Date Contractor OTHER(SPECIFY) P A�9
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from the Contractor's License Law for the following reason. p�� 4� �
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to d �^!LHJI
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 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 the alleged ASPHALT SHINGLES d7rfL(, f�tN RNO
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to �(xs✓ 6z
eci�vil penalty of not more than five hundred dollars($500).):
"yt-^✓ �L
l,as owner of the property,or my employees with wages as their sole compensation,will do ,WOOD SHAKES FIIf7 ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profess c/
slons Code: The Contractor'a License Law does not apply to an owner of property who builds or WOOD SHINGLES P ❑
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
Is sold within one year of completion,the owner-builder will have the burden of proving that he did 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(See.7044,Business and Professions Code:The Contractor'.License Law tloes 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 a contractor(s)licensed pursuant to the Contractor's License Law, PROVIDE MFG R. INSTALLATION SPECS.
1 am exempt under Sec. ,B 8 P.C.for this reason
Owner e J no e �Z-2' APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION —
I hereby affirm under penalty of perjury one of the following declaration: '7000
C]I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, Building 112-121)
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. - 7/9
x Seismic
have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
the Labor Code,for the pertormanda of the work for which this permitit ississued.My Worker's Q
1 Compensation Insurance carrier and Policy number are: / Total
Carrier Policy No. 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.)
1 certify that in the performance of the work for which this permit Is Issued,I shell not employ
any person m any manner so as to become subject to the Workers'Compensation Laws of Cali- All roofs shall be inspected prior to any roofing material being
minis. installed. If a roof Is installed without first obtaining an
Dat Applicant ��l �--- -- inspection,I agree to remove all new materials for inspection.
O CE TOA PL06011'If after makln INs Certificate of Exemption,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP P Y P
with such provisions or this permit shell be deemed revoked. source regulations.
I certify that I have read this application and state that the above information Is correctI agree
to comply with all city and county ordinances and state laws relating 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 for in-
spection purposes.
(We)agree to save, Indemnify and keep harmless the City of Cupertino against liabilities, & l ./Jru moi— 7 97
judgments,costs and expenses which may In any way accrue against said City In consequence
of ma granting of this permit. GNATUR PPLICANT 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