R 5468 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R_ 5468
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 777-8228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
10505 15 Blvd. RESIDENTIAL
COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AR
YESIt yes-I understand that a Class A
E
NAM ' lJ� YI-f roof assembly is required.
NO ❑ Initial I.C.B.O.ff
ADDRESS I.C�5b5 5 , ,t,{!( vEXISTING R`"ERING
PHONE
� r✓�— NUMBER OF EXISTING COVERING I
CONTRA TORI "�'
NAMEJ( (`,� TO BE REMOVED I TO BE RETAINED
ADDRESS ,r �p ' .^ TYPE OF ROOF COVERING
CITY 8 ZIP
n EXISTING
PHONEf-O8) +_5?S5 BUILT-UP ROOF ❑ -
LICENSE
NUMBER D ASPHALT SHINGLES B❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 0(commencing with Section WOOD SHAKES
7000)of Dlvlelon 3 of the Business end Professions Code,and my license le In full force and all
enact. /
WOOD SHINGLES 41®br�z�,r
License Class G Lic.Numbs �"'7
Date I!¢/ ` ' Contractor �% OTHER (SPECIFI���'OF
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the f owing reae
(Sec.7031.5,Business and Professions Coda: Any city or county which require armlt o
applicant,alter.Improve,demolish,signed statement
anystructure,is licenseor to issuance,pursuant ributinto the r e BUILT-UP ROOF ❑ •
construct for such permit to Ills a h,orrestatement that he Is licensed pursuant to the provisions
of the Contractor's License Law(Chapter B(commencing with Section 70001 of DMIon 10 the
• Business entl Professions Code)or that he le exempt therefrom and the heels for the alleged
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to ASPHALT SHINGLES
a civil penalty of not more than five hundred dollars($500).): t yV
❑I,as owner of the property,or my employees with wages as that,sole compensation,will do WOOD SHAKES ❑ /G
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and PrCfes.
stuns Code:The Contractors 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 Me own employees,provided that ❑
such Improvements are not Intended or offered for eels.If,however,the building or Improvement
is sold within one year of completion,the owneabulitler will have the burden of proving that he did SPECIFY
not build or Improve for purpose of sale.). OTHER(SPECIFY) ❑
❑I,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 Lew 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 contrector(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 em exempt under Sec. ,B 0 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
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, Building[
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this _
permit is Issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of ,I�,'//y 14 Icir(f� Seismic
the Labor Code,for the performance of the ork for which this permit Is Issued.My Worker's
Compene Insur nce c ntl Policy u her are: q Total
Carrier " J Policy No. 1-7 PERMIT AUTHORIZATION DATE
CERTIFICATE OF E%EMPTION FROM WORKERS
COMPENSATION INSURANCE N.C.O t
(This section need not be completed If the permit Is for one hundred dollars($100)or lees.)
I certify that In the performance of the work for which this permit Is Issued,I shell not employ
any person In any manner so as to become subject to the .,kers'Compenaatlon Laws of Call. All roofs shall be inspected prior to any roofing material being
fornix' installed. If a roof is installed without first obtaining an
Data „ Applicant ✓ inspection,I agree to remove all new materials for inspection.
NOTICE TO become
subject to the Workers'Compeneatlon provlafter eloms of the this lLabor Code,cate of yyou myt fort wllth comply Applicant understands and will comply with all non point
with such provisions or this permit shall be doomed revoked. Source regulations.
I certify that l have read this application and state that the above Information Is correctl some
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 me above-mentloned property for In.
spection purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, �i•p V` CI
jutlgments,costa and expenses which may In any way accrue against said City In consequence
of the granting of this permit. SIGNATURE OF APP NT DATE
PRE-INSPECTION: PLYWOOD: - IN-PR ESS:
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