R-5441 (2) PE
APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 5441
INSPECTION DIVISION PERMIT EXPIRATION
REROOFPERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
' 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
/ozrs- 06 few /4ec RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME roof assembly is required.
NO Initial LC B.O.41
ADDRESS C .ILi EXISTING ROOF COVERING
PHONE - NUMBER OF EXISTING COVERINGS '
CONTRACTOR'S IO
TO BE REMOVED TO BE RETAINED
NAME
ADDRESSS• •�` L TYPE OF ROOF COVERING
CITY&ZIP rc S"d s s . J 7 EXISTING41040) .
PHONE Z7 Z� J6 BUILT-UP ROOF ❑
LICENSE
NUMBER Z ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
lrm
I hereby al that I em Ilcensed under provisions of Chapter S(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
affect.
yL✓37 Z WOOD SHINGLES ❑
License Class _ Lic.Number 7 r
Date ' contractor AZ 60m.�A �n� OTHER(SPECIFY) ❑
OWNER-the Conn DECLARATION PROPOSED
hereby affirm Bu that am exempt from the Contractor's or coup Law for the fallowing reason.
(Sec.70315,Business and demolish,
or re Coda: Any city or county which requires a permit to
construct,alter,such prove,ermit to file signed air any staementrthate,prior toIts Issuance,alsoregsreslns BUILT-UP ROOF -32
applicant for such permit to file a signed statement that he Is licensed pursuant to O the provisions
at the Contractor's License Law(Chapter 9(commencing with Section]000)of Division 3 of the (Q )
ex
Business ptio end violation Of Code)or that he Is exempt therefrom and the jbasis for the eclat-d ASPHALT SHINGLES /_n
exemption.Any f violation on of Section hundred
by any applicant for a permit subjects the applicant to
e civil penalty of not more than Ilya y employees
dollars with
WOOD SHAKES
❑I,as owner of the property,t I to employees with wegee as their sole compensation,will do C
the work,and the structure is not Intended or off-red for eels(Sec.7044,Business and Profen- 6
sone Cotla:The Contractor's License Lew does not apply to an owner of property who builds or WOOD SHINGLES ❑
Improves thereon,and who doessuchwork offered
or through his awn employees,provided that
such Improvements are not completion,
leb n,of owner-builder
for edea. ill however,the en of pr or Improvement
Is notsold bull or
prove for purposetof sthe owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build ar Improve icer purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractor&to construct
the project(Sec.7044,Business and Professions Cotle: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 contractogs)licensed pursuant to the Contractor's License Lew, PROVIDE Ml INSTALLATION SPECS.
[:]I am exempt under Sac. ,B B P,C.for this reason
Owner trete APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the lollowing declaration: l4 If D
❑I have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, BU
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this AIUs
permit is issued. {/ ���
25
❑ have and will the pert Worker's Compensation the workfor Insurance,hickthis as required 13 I su Section 3700's e
the Labor Code,for the performance of the work for wMch this permit Is Issued.My Worker's C,'T"UFC tel
0—
Compensation Insurance carrier and�Policy_number are: �f!r ,
Carder ST��0_ Policy NoC 90 GIDD�t PERMIT AUTHO ION 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 lass.)
I certify that In the performance of the work for which this permit Is ft d,I shall not employ
any person In any manner so as to become subject to the W ars c --..tion Laws of call- All roofs shafte in ected prior to any roofing material being
fornix. Lr� 7 installed. If a roof is installed without first obtaining an
Data / Applicant inspection,I agree to remove all new materials for inspection.
NOTICE a APPLICANT: II,atter maklngprovis this f the
Ede,you musttfo thwlithbecome comply Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the La r Code,
with such provisions or this permit shallIbe deemed revoked. SOUTCe regulations.
I certify that 1 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 coverings to blass"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for Irl
spection purposes. g� '1_�/rte
(We)agree to save,Indemnify and keep harmeass the City of Cupertino against liabilities,
judgments,costs and expenses which may In any way accrue against said City in cronsequenca GNATURE APPLICANT DATE
., of the granting Of this permit.
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