R-5532 (2) PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 5532
INSPECTION DIVISION PERMITEXPIRATION
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 /��J f
/ 3 / yG Z�G /`� � RESIDENTIAL - COMMERCIAL OTHER -
OWNER'S HAZARDOUS FIRE AREA
7 YES ❑ It yes-I understand that a Class A
NAME cc�' �G ��•�/ S roof d
assembly is required!
Initial_ LC.B.O.M
ADDRESS CP_/3/ 7 ���C" /— EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
TO BE REMOVED ZTO BE RETAINED
NAME
ADDRESS
h ��- TYPE OF ROOF COVERING
I O'
CITY&ZIP �/�LO/.y ��
EXISTING
PHONE�/ O �� BUILT-UP ROOF ❑
'LICENSE
NUMBER / /'7 _56
ASPHALT SHINGLES ❑ �� (� -
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES !'
7000)of Division 3 gLlhe Business and Professions Coda,and my license Is in full force and 7
effect. C /
�J, .) 71 � 73Z WOOD SHINGLES ❑ Y�
License 's 1� " � Lie.Number-r
OTHER(SPECIFY) P A I n
Data Contractor B
OWNER-the Co R DECL Licen PROPOSED
lrATI
hereby affirm that am exempt from the Contractor's Licen a Law for the fallowing reason. J
(Sec.7ct,alt Business and Professions Code: Any city or county Iwhichssue requires a requires
to /
construct,alter,Improve,demolish,file siorrepairenystructure,prior toits Issuance,alsorequires the BUILT-UP ROOF"
applicant for such permit to file a signed statement that g with
Sectio pursuant to the provisions
of the Contractor's License Lew(Chapter h(commencing with Sectlon 7000)o/Division 3 of the
. Business and violation of Cede)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES 0-
exemption.Any violation of Section hundred
by any applicant for a permit subjects the applicant to
e civil penalty of not more than five ey employees
dolyeesrs(h wag 1: WOOD SHAKES❑I,as owner of the property,or to ded or of a with wages as their solo compensation,will do ❑
the work,and the structure is net intended or offered for sale n owner
of Business and Proles-
cionsCode:The,an who
License Lawdoes elf apply to or
his min
property whoidebuilds or WOOD SHINGLES ❑
improves thereon,entl who does such work himself or through his own employees,provided that
such improvements are not Intended orowoffered for sale. ill however,the enofbuilding proving
oiImprovement
nSold tbuild or
prove for purposelioatheowner-builderwill have the burden of proving that he did OTHER(SPECIFY)
C
not build or Improve for purpose of sale.).
❑I,as minor 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 Ne
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contmctons)licensed pursuant to the Contractor's License Law. PROVIDE full INSTALLATION SPECS.
❑I am exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FE
r WORKER'S COMPENSATION DECLARATION
_ 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 Workers Compensation, Zf BUlldln
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. / .r�- Sem
' ❑I have and will m mmin Worker's Compensation Insurance,as required by Section 3700 of /.I�OQr/-
t�F I
the Labor Code for a pedormancgpvtIt work for which this permit is Issued.My Workers V
Complain ns ante rrler a P c number are: Total
carrier s Policy No. Fs7 - PERMITAUTHORIZATI
CERTIFICATE OF EXEFAPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need not be completed if the permit is for one hundred dollars(5100)or lass.)
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'Compensation Laws of Cali. All roots shall be irfspeCted prior to any roofing material being
forma. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOT Cecome
subject toE
Ethe Workerss'Compefnsati n proviTO APPLIANT: I,after sionis ofetheoLabor Code,yoou mustuforthwlithsoudbcomply Appl' tunderstands and will comply with all non point
with such provisions or this permit shall be deemed revoked. S icer ulatei -
I certify that I have reed 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 Il roof verings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property or in- t
spathe)purposes. ^
(We)agree to save.Indemnity and keep harmless the City of Cupertino against Ilabllities,
judgments,costs and expenses which may In any way accrue against said City in consequence SIGNATUR F 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