R-5555 (2) APPLICATION FOR CITY OF CUPERTINO
NUMBER PERMIT
R- 5555
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.
j� BUILDING ADDRESS mow,/,
.2/d 83 � � RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
VES ❑ If yes—I understand that a Class A
NAME roof assembly is required.
NO ❑ Initial I.C.B.O.It
ADDREss ?�— EXISTING ROOF COVERING
PHONE 2-55 7- 3 S NUMBER OF EXISTING COVERINGS
CONTRACTOR' ,� n
NAME
' vGmy/— TO BE REMOVED / TO BE RETAINED
� ���+ q
ADDRESS / TYPE OF ROOF COVERING
CITY&ZIP �'Q
q EXISTING
PHONE (o l L / BUILT-UP ROOF ❑
LICENSE A$PHA
NUMBER � (r ( � �l � ❑
LICENSED CONTRACTORS DECIARATION
I hereby affirm that I am licensed under provisions of Chapter 0(commencing with Section woo SHAKO
7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and
(/
Liceffense
Ck
2-G woo INGL S 01 1997 License ClaLic.NumberOTHERDale Contractor ER BUILDER DECLARATION PROPOSED
1 hereby affirm that am exempt from the Contractors License Lew for the requires
ng reason.
cons.7031.5,Business and Professions Code: Any uor county which requires a permit to
construct,altar,Improve,to file signedrepairstatement
anystructure,prior to its issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to lila a signed oatemem that he is licensed pursuant to the provisions
of the ss and
License Lew(Chapter 8(commencing with Section 7000)of Division 3 of the -
• Business antl violation of Code)or that he Is exempt therefrom and the basis he the applicant
to ASPHALT SHINGLES
exemption.Any flotation 01 healon 7031.5 by any applicant for a permit subjects the eppliwnt to
e dull penalty of not more than flue hundred dollars(8500).):
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not intended or offered for sale(Sec.7044,Business and Farm.
slons Code:The Contractor's 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 ante.If,however,the building or Improvement P A I (`�,(,{/,--G-/�,•a' J
is cold 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.). t
❑I,as owner Of the property,am exclusively contracting with llcensetl contractors to construct
q
the project(sec.7044,Business and Professions Cade:The Contractors License Law does not PROVIDE .IETCQREPIWDJO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor($)licensed pursuant to the Contractors License Law.
C] P. PROVI�FdRGRJTAI�IJ TION SPECS.
I am exempt under Sec. ,B& 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: 2? 7
r-1I have and will maintain a Certificate of Consent t0 sell-insure for Worker's Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this p / Q�
perm Is issued. 912-L / 7 1.71 110 Seismic o^
ave and will the performance
Worker's Compensation Insurance,as required isi issued.
d.My
3700'of
s 1
C Labor Code,for the performance of the work for which this permit is issued.My Worker's
Comports In ran car le antl PoI number era: Total
Carter Policy No. sy PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N C.0 T
(This section need not be completed If the permit Is for one hundred dollars($100)or less.) v Q 0 n
I cersty that In the performance of the work for which this permit Is Issued,I shall not employ T I1
any person In any manner so as to become subject to the Workers'Compensation Laws of Call. All roofs shall be inspected prior to any roofing material being
torrid. installed. If a roof is installed without first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
NOTCE subject I.theOWoPerss'Compelnsation provisioAPLIANT. I,after makinns of theiLaborr Coca Yolumust fothw!thbcomply Applicant understands and will comply with all non point
with such provisions or this permit shaltbe 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 verings to be class"C"or better.
hereby authorize representatives of this dry to enter upon the above-mentioned property for in- ��'/� �� Aherebon purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, �G
judgments,costs and expenses which may in any way accrue against said City in consequence
of the granting or this permit. SIGNATUR FAPPLI ANT 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
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