R 5044 (2) PERMIT R_ 504
4
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN IBD DAYS OF PERMIT ISSUANCE OR
. 100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
p330 �. t15, II(JllJf/\• A^, � SIDENTIAL k�COMMERCIAL OTHER
OWNER'S /� HAZARDOUS FIRE AREA
YES ❑ It yes—I understand that a Class A
NAME , �esf 1 `-�'�' roof assembly is required.
\r �/ I NO ❑ Initial I.C.B.O.R
ADDRESS`I' `�`� oAw o z EXISTING ROOF COVERING
PHONE T,J' 3 2_�_ y O Z ' NUMBER OF EXISTING COVERINGS
CONTRACT 'S 4^
NAME a L TO BE REMOVED TO BE RETAINED
ADDRESS p vµ� {, `r ��aG G TYPE OF ROOF COVERING
CITY&ZIP 1 w
PHONE 3 0 EXISTING
BUILT-UP ROOF ❑
LICENSE O G_3 ASPHALT SHINGLE
NUMBER ❑
LICENSED CONTRA TORS DECLARATION
1 hereby affirm that 1 em licensed under provisions of Chapter B(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and /
effepL WOOD SHINGLES
License Claes Uc.Number /
Date Contractor
OTHER(SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason, y
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to rL-6SxJ
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 Licence Law(Chapter g(commencing with Section 70001 of Division 3 of the
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of not more than five hundred dollars(5500).):
C]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 Bele(Sec.7044,Business and Protas-
alone Code:The Contractor's License Law does not apply to an owner of properly 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
Is sold within one year of completion,the owner-builder will have the burden of proving that he d[d OTHER (SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors 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 Contractors License Lew, PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
'
I hereby allirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to Belbinsuro for Worker's Compensation, Building1`07
e for by Section 37000/the Labor Code,for the performance of the work for which this
permit
permitmit is le Issued. ou �7jO Seismic
❑ have and will the performance
Worker's Compensation the wokfor Insurance,as required by Section 3700 of
the Labor Code,for the pedormand of the work for which this permit Is Issued.My Worker's I C
Compensation Insurance terrier end Policy number`tare: Total L2?1—
Carrier Panic CERTIFICATEIO WORKERS' PERMIT AUTHORIZATION DATE
COMPENSATION IRANCE N.C. r �� ^�
(This fy that I need not r ante of the
II ma per s for one hundred tlolle a($100 r 4V Ci
I tartly that In the performance of the work I Is ermit I n employ
any person In any manner So as o become a to the omp edon La s of caft. All roofs shall be ny roo Ing material being
forms.
��/ installed roof is installed wit rut first obtaining an
Date I Applicant ome ins p on,I agree to re ova all new terials for inspection.
E TO subject t.the Workers'Compefnsation pa leI No olethe lLabor Code.cate of you mll uetuf Inwiihbcomply pylic t understand nd will co ly with all non point
with such provisions or this permit shall be deemed revoked. Sour regulations.
I certify that l have read this application and state that the above Information correct.I agroe
to comply with all city and county ordinances and state laws relating to bulldin onstructlon,entl All f verin S flet.
hereby authorize representatives of this city to enter upon the above-mor to d ktoper ty for In _
epection purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino go Inst 11 bllltles,
judgments,costa and expenses which may in any way accrue against sola City In consequence
• of the granting of this permit. NATURE OF I DATE
PRE-INSPECTION: PLYWOOD: I -P OGRESS:
INSP. DATE t INSP. DATE I DATE
TEAR OFF INSPECTION: '( BATTENS: FINAL:
INSP. DATE 4 4.d' INSP. - ' DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY