R 5488 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 5488
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARrED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
BUILDING DRESS 180 DAYS FROM LAST CALLED INSPECTION.
I ADDRESS
��" "► /,ICO �O �� RESIDENTIAL COMMERCIAL OTHER
OWNER'S ) HAZARDOUS FIRE AREA
(�,! Q /f� YES ❑ If yes-I understand that a Class A
NAME "--`4a'�� "-�-�'-o""a"�� roof assembly is required.
NOInitial I.C.B.O.q
EXISTING ROOF COVERING
ADDRESS—
PHONE
�j f,
PHONE (1vol ) �O /_/�� NU BER OF EXISTING COVERINGS
CONTRACTOR'S x
TO BE REMOVED TO BE RETAINED
NAMEQ
ADDRESS (! TYPE OF ROOF COVERING
CITY&ZIP /b5 o S a-r. n 'sr
EXISTING
PHONE y f 74 fLSG BUILT-UP ROOF [ti'
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter B(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license is In lull force and
effect
Z WOOD SHINGLES ❑
License Class Lic.Number
/-+ `a ❑
ell
Date / �/ � Contractor OTHER(SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED
hereby alible that 1 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,alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF ®'
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Law(Chapter 0(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 Elexemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500).): WOOD SHAKES
❑1,as owner of the property,or my employees with wages as their sofa compeneallon,will do ❑
the work,and the structure is not Intended or offered for sale(See.7044,Business and Profes-
sionsCode:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES El
thereon,and who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for sale.ll,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or improves thereon,and who contracts for such projects
with a contracer(s)licensed pursuant to the Contractors License Law, PROVIDE MFGR.INSTALLATION SPECS.
❑1 em exempt antler Sec. ,B 8 P.C.for this reason ,
Owner Data APPLICATION DATE VALUATION PERMITFOK
WORKER'S COMPENSATION of th ION DECLARATION Pict
hereby affirm under penalty of perjury one o/inn following duce for o �,VV s�„
❑I have and will maintain a of the Lab of Consent or to Performa for Worker's Compensation, yrsy't71BR" Bund!
as provided for by Section 3700 0l the Labor Code,for the performance of the work for welch this
permit Is Issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 o1 -'tNNQ �y/y�•� 3ei$rT',
the Labor Coda,for the performance of the work for which this permit Is Issued.My Workers ✓�\1/ Total
Compensation InsuranEe carrier and Policy number are:
CarrlerwAA�.t/ oglleyN E-8 iii 0 �3/3 (a PERMIT AUTHORIZATION DATE
CERTIFICATE OF XEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.
(This section need not be completed If the permit Is for one hundred dollars($100)or tem)
1 cenily that In the performance of the work for which this permit Is Issued,I shall not emptoy
any person In any manner so as to become subject to the Workers'Compeneatlon Laws of Cali- All roofs sh I be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
subecct to the WAorrke aCcompense Tormaking
proimalons of theCertificate
LaborCode,you mtion ust forthwith omply Applicant understands and will comply with all non point
with such provisions or this permit shall 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 laws relating to building construction.and All roof coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
sp(We) purposes. // ^ 97
(We)agree s save,Indemnify and keep hay way the City ai Cupertino against liabilities,
judgments,casts and expenses which they In any way accrue against said Clry In consequence SIGNATURE OF 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