R 5087 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 5 8 7
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 LASTCALLED INSPECTION.
BUILDING ADDRESS r f- /A�
G'O (y '!� RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME �/ Y roof assembly is required.
O Initial I.C.B.O.u
ADDRESS EXISTING ROOF COVERING
PHONE �Ilr
NUMBER OF EXISTING COVERINGS
CONTRAC
TO BE REMOVED TO BE RETAINED
NAME_ S v '
ADDRESS Z-nrWK0D, x//f P F COVERING
CITYBZIP /C �E'XIISTING
PHONE .51d a� 93da BUILT-UP ROOFLICENSE
❑
NUMBER 20 O ASPHALT SHINGdE
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES
7000)of Dlvislon 3 of the Business and Professions Code,and my license is In full force and �j i
effect. WOOD SHINGLES ipi"
License Class Us.Number CM11%
Dale Contractor
OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors License 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,ship requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contmotais License Law(Chapter g(commencing with Section 70001 of Division 3 01 the _ A
• Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES 1/�A
exemption.Any violation of Section 7031.5 by any applicant fora permit subjects the applicant to
a civil penalty of not more than live hundred doliare($500).1:
❑1,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 Profits.
alone 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 safe.If,however,the building or Improvement
Is sold within one year of completion,the owner-bullder will have the burden of proving that he did OTHER(SPECIFY) Elnot build or improve for purpose of sale.).
0I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Law 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 a contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTA TIQN SPECS.
❑ em exempt under Sec. ,B 8 P.C.for This reason H IG Z 99
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: /
❑Ihave ed andfort Sectiill on
t3700 of the
ate bol Consent the perforInsumance
Worker's Compensation. 6 ,/1�/ Buildings
permit is Is forMSection 3700 of the Labor Code,for the pedormanee of the work for which this (vl1r/'1//[/ I
permit v and /f- Seismic
❑ have and will the performance
Workers Compensation Insurance,as permit is i by Section Workers
0l [TV%
the Labor Code,for the performance of the work lar which this permit is Issued.My Workefekly 7
Compensation Insurance carrier and Policy number are: Total J
Carrier Policy No. PEWITAUTHORIZATI N DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed If the permit Is for one hundred doll 100)or leas.) 1 /1- A.�
I certify that in the performance of the work for whl hie permlCis I etl shall not employ
any pars In any manner so e9 to become eubjeM h rkera' perflation Laws of Cali. II roof."
shall be inspected prior to any rooting material being
fornia. 'j/�/ installed.-It a roof is installed without first obtaining an
Date -" Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making ThirCertificate o xefWtmn,you should become Applicant subject to the Workers'Compensation provisions of the Lab Code,you must forthwith comply PP understands and will cpm ply with all non point
with such provisions or this permit shalgbe doomed 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 toy
co1 erin a Class"Ci"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes. l Ad 11�
(We)agree to save,indemnify and keep harmless the City of Cupertino against Ilabllltles.
judgments,costs and expenses which may In any way accrue against said City In consequence CFO
of the granting of this permit AN AT U APPLICANT DAT
• 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