R 5150 (2) PERMIT R_ 5150
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777.3228 PERMIT EXPIRES IF WORK 19 NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM UST CALLED INSPECTION,
BUILDING ADDRESS
` 1 R ESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
\ Q 7 / (- 4` z^ ,(�.2 VES ❑ If yes sembly is requireI understand that d. Class
NAME lJ IT fJ-V_ `-,1 JCJ
/ G NO Initial _ I.C.B.O.H
ADDRESO"' l P 1c: r . P�.�9C%-F EXISTING ROOF COVERING
PHONE �— NUMBER OF EXISTING COVERINGS /
CONTRAC OR'S
`,V\�� TO BE REMOVED / TO BE RETAINED
+.NAME
ADDRESSZ v. TYPE OF ROOF COVERING
CITY&ZIP l� O C EXISTING
PHONE 6 7— � I � � BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SH910E 4 1996
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 8(commencing whh 9 n WOOD SHAKES
7000)of Division 3 0l the Business and Professions Code,and my license le In lull e d -�, r I I
effect. C / C WOOD SHINGLES U ❑
License Cla Llc.Numb F
Date f t corny ctor OTHER(SPECIFY) !Vd
OWNER-BUIL LARATiN PROPOSED �grF�oop Fo
I hereby affirm that I am exempt from the Contractor's License Law r the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to r e
construct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF � T
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractors License Law(Chapter 9(commencinp with Section 7000)of Division 3 of the
. Business antl Professions Code)or that he ie exempt 18,81rom and the basis for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant tb
e civil penalty of not more than five hundred tlollare($500).): ^ J
❑I,as owner of the property,or my employees with wages as their able Compensation,will do WOOD SHAKES
the work,and the structure Is not Intended or offered for sale(See, 044,Business and Proles.
alone Code:The Contractor's License Law does not apply to an owner of property who bukds 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.If,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 contrectogs)licensed pursuant to the Contractors License Lew. PROVIDE MFGR.INSTALLATION SPECS.
E]I em exempt under Sec. ,S a P.C.for this reason
Owner oats
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 sell-insure for Worker's Compensation, Building12-7
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit lavean. Seismic O
/1�abor rend will maintain Worker's C the wok for Insurance,ae required by d.My or X)of U/ ,�
lite Labor Code,for the performance of the work for which this permit le Issued.My Worker's
Comperz Co lnerencecarrler�an'tl Policy/�/�umbar are. /C/%,� L/ Total
Carrier `��� (J�,r✓C Policy NJ�4./-116.22?-- ? PERMIT AUTHORIZATION DATE
r CERTIFICATE OF EXEMPTION FROM WORKER§'
COMPENSATION INSURANCE N.
(This section need not be completed If the ill I ne hundrotl of "am
00 or leas.) .2
I certify that in the rformenca of the work int which t e pbrmlt le issued, shot 0'.
f em
any person In y ma er so as to become subject to ih worker compo anon awe of All roofs all be inspected prior to any roofing material being
forma' installed. If a roof is installed without first obtaining an
Date A. ant �' inspection,I agree to remove all new materials for inspection.
Non TO PLICANT: II,aff r meld a Cuw qq z pilo ,you ehoultl become A licant understands an I cont
subject o the Workers'Companaetlo visions of the LabdrC e, must lorthwlth comply PP ply with all non point
with e il provlsioaa or this permit shall ba tleemed revoked. Sour BgulatlonS.
I certify that l have read This application end elate that the above Inlormallon Is correct.)agree
to comply with all Illy and county ortlinancee antl state laws relating to bulltling construction,antl All OOf OVerl StOb Cla "O"Or tter.
hereby authorize rapresentatives of Ihle city to enter upon the ebove•mentlonetl property far In• q
spechon purposes. / �( s�
(We)agree to save,indemnify antl keep harmless the City o/Cupertino against Ilebllltlee, ,�•-. L'
jutlgMonts,costs and expenses which may In any way accrue against geld Clty In conaequenca
ju the granting o1 me
permit. UR LICANT ATE
PRE-INSPECTION: PLYWOOD: I -PROGRESS:
y INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY