R-5527 (2) APPLICATION FOR CITY OF CUPERTINO.
PERMIT 5527
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 LAST CALLED INSPECTION.
BUILDING ADDRESS
7007 0 I4I ESIDENTIAL COMMERCIAL OTHER
NE S HAZARDOUS FIRE AREA
YES ❑ It yes-I understand that a Class A
NAME root assembly is required.
�� r ' NO Initial I.C.B.O.k
ADDRESS Ib/"'rLooO EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS '
CONTRACTTOOR'S �./�
NAME `� �r/� -I TO BE REMOVED�TO BE RETAINED 0
ADDRESS
s` �l/L
TYPE OF ROOF COVERING
CITY&ZIP a o EXISTING
PHON`(/P 0 7-44 � /677
BUILT-UP ROOF
CENSE
NUMBER
3 7 Z ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES fJ.
7000)of Division 3 of the Business and Professions Code,and my license is in full force and
effect.
G 3 9 NZ y ?7 Z WOOD SHINGLES ,� D❑
License Class Lic.Number �
8 Z s. y' E 1 OTHER(SPECII� f� ❑
Date � Contractor ® A
OWNER-BUILDER DECLARATION PROPOSED C/T}. �CQ
I hereby affirm that I am exempt from the Contractor's License Lawlor the following reason. Oh
(Sac.7031.5,Business and Professions Code: Any city or county which requires a permit to C
construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the BUILT-UP ROOF �T'FHTIN(� .
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law(Chapter 9(commencing with Section 7000)0,D I v1sho n 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
a civil penalty of not more than live hundred dollars($5001J: WOOD SHAKES
I,as owner of the property,or my employees with wages as their sole compensation,will d0
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profes-
sioasCode: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 sale.ll,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY)
not build or Improve for purpose of sale.).
❑I,as owner of the property,am 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 contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR. INSTALLATION SPECS.
❑I am exempt under Sec. ,B&P.C.for this reason
Owner Data APPLICATIONDATE VALUATIO T
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: T ��
F-1I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, V BUII
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this (/�
permit is Issued. {/ 25ve Sels IC
❑I haand will maintain Worker's Compensation Insurance,as required by Section 3700 of /�
,the Labor Code,for the performance of the work for which this permit is Issued.My Worker's C/
Compensation Insurance carrier and Policy number are: TY Uf `•U Total
Carrier 12M)W �-I�✓Jf>_ Policy No.47/-1p` 000f PERMIT AU IZATIO DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.I]
(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 shall not employ
any person In any manner so as to become subject to the Workers'Compens 'on Laws of Cali. All roots shall be inspected prior to any roofing material being
lornlaQ installed. If a roof is installed without first obtaining an
Data ? Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It,after making this Certificate o molten,you should become Applicant understands a com I all non point
subject to the Workers'Compensation provisions of the Labor ode,you must forthwith comply p y p
with such provisions or this permit shafte deemed revoked. source regulations.
I certify that I have read this applicallon and state that the above information is correct.)agree
to comply with all city and county ordinances and slate laws relating to building ccnstructlon,antl All roof'coverin IOb SS Or Iter.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
erection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs and expanses which may in any way accrue against said City in consequence .00511
• of the granting of this permit. SIG ATURE PL DATE
PRE-INSPECTION: PLYWOOD: IN-PROGR SS:
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 _ _ _