R 5112 (2) PERMIT R_ 5112
APPLICATION FOR CITY of CUPERTINO NUMBER
INSPECTION DIVISION PERM IT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
• 1 B DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
/85 ri
3t S 7' 7q,,� B/vp
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
�r
.l�tl YES ❑ If yes-I understand that a Class A
NAME N WeAA;&v roof assembly is required.
t / NO Initial I.C.B.O.Ir
ADDRESS �t DO f `U C.-!e EXISTING ROOF COVERING
Y (� NUMBER OF EXISTING COVERINGS
PHONE ,
• CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS a n ,/ �� '�S -G*PE OF ROOF �
CITY&ZIP <7 EXISTING
PHONE 5W- U3 '70219 BUILT-UP ROOF ❑ `
LICENSE 6 d Z. ASPHALT SHINGLES
NUMBER
LICensed CONTRACTORS DECLARATION
hereby affirm that em licensed under Professions
loss of Chapter B(commencing with Section and WOOD SHAKES Q/ /
7000)of Division 3 of the Business and Profeaelone Code,and my license Is In lull force entl
effect. WOOD SHINGLES
License Claes C Llc.Number 7— ❑
Data g/1� 9 contractorOTHER(SPECIFY) ❑
OWNER-BUILDER ECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,altar,improve,demolish,or repair any structure,prior to Its issuance,also requires the BUILT-UP ROOF �I
applicant for such permit to Ills a signed statement that he Is licensed pursuant to the provisions III^^^[[(—Jff re
• of the Contractor's License Law(Chapter B(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
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 dollen($500).):
❑I,as owner of the property,or my employees with wages as their able compensation WOOD SHAKES ❑
the work,and the structure is not Intended or offered for sale(Sec.7044,Busine roles.
slons Code: The Contractor's License Law does not apply to an owner of ywho builds or WOOD SHINGLES
Improves thereon,and who does such work himself or through his ployees, rovided that ❑
such Improvements are not Intended or offered for sale.If, or,the building or Pmprovement
Is sold within one year of completion,the owner-bull eve the burden of proving that he didOTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,as owner of me properly,a elvely contracting with licensed contractors to construct
the project(Sac.7044,Bu and Professlons Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an ownor of try who bullds or improves thereon,and who contracts for such projects
with econire Ileeneed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑ exempt under Sec. ,B a P.C.for this reason
Owner Dem
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Build!11� /�l�
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this y��;\.-sa��J{—�
r permit le I ued. AUG BBISRIIC `�r
ave
and will maintain Workers Compensation Insurance,as required by Section 3700 of 21 1996 G
the Labor Code,for the penormance of the work for which this permit Is Issued.My Workers JJJJC�dd
• Compensattlon su be carrier end Policy number are: Q / Total
Carrier / rP �O Policy No.�/ -3^�LZ "'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.)
I certify that In the performance of the work for which this permit Is Issued,I shell not empIby
any person In any manner so as to become subject to the Workers'Compensation L e of Cell- All roofs shall be inspected prior to any roofing material being
forma. installed. If a roof is installed without first obtaining an
Dale Applicant inspection,I agree to remove all new materials for inspection.
subjeWto the APPLICANmpensatlon provisionl&of theLaborCod,yyou munlaroinwlith comply Applicant understands and will comply with all non point
with eu rovlslons or this permit shell be 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 lawn relating to building construction,and All roof coveringst be I SS" i"Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes. e i
g(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, (jj �/ Z
oIlea gr�antlnpeol tole pa�mlL ae which may In any way accrue against said City In<onaequence IGNATURE F APPLICANT 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