R 5206 (2) �4aagl
PERMIT R_ 5206
APPLICATION FOR CITY OF CUPERTINO NUMBER
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
L.0 - � (Z�� RESIDENTIAL COMMERCIAL OTHER
OWN S HAZARDOUS FIRE ARE
K VES o yes s I understand that a Class A
NAM oof assembly is understand
that
tj NO ❑ Initial I,C.B.O.If
ADDRESS EXISTING ROOF COVERING
`
• PHONE / a `��G� NUMBER OF EXISTING COVERINGS
CONTR 'Sc
NAME
t! TO BE REMOVED TO BE RETAINED
ADDRESS3 _/ . 5 TYPE OF ROOF COVERING
CITY +J � 1
/ — u A. _ EXISTING Al
PHOW` o BUILT-UP ROOFLICENSE
qql CGIFO
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTOR CLARATION le
I hereby affirm that I am licensed under provisions of Chapter S(commencing with Section WOOD SHAKES � �
7000)of Division 3 of he Business end Professions Code,and my license Is In full force and f
effect' Oqy WOOD SHINGLES 9'flJ
Licenel Cela Lia Number '�'►7�-� /
Datil Contractor f✓ "w"�'f OTHER(SPECIFY) ❑ b
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Professions Coda: 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 El
for such permit to file a signed statement that he is licensed pursuant to the provlalone
of the Contractor's License Law(Chapter a(commencing with Section 7000)of Dlvislon 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 five hundred dollars($500).):
r
C-)1.as owner of the property,or my employees with wages as their sole compeneetlon,will do WOOD SHAKES U
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes- • i .. r
Bions Code:The Contracto(s License Law does not apply to an owner of property who builds or WOOD SHINGLES M/'V
Improves thereon,and who does such work himself or through his own employees,provided that f
such Improvements are not Intended or offered for sale.It,however,the building or Improvement T4.
issold within one year ofcompletion,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 Prolesalons 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 contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
E]I am exempt undo,Sec. ,B 8 P.C.for this reason
Owner Date APPLICATIO TE VALUATION PERMIT
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
q ❑1 have and will maintain a of the
o Consent to self-insure for Worker's Compensation,which
this B W j�lr11�
pe provided Is for by Section 3700 of the Labor Code,for the performance of the work for which this �T .g C Sel(�7��`//
permit Is Issued. IIGI� JS qY x9
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of / _ s
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's 1 `R-�VWri
r Compensation Insurance carrier and Policy number are: e Ie� C� CITY OF GUeLH I IN Total
Carrier Policy No.L�?�_ PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need not be completed If the Permit Is for one hundred dollars($100)or less) b _
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 sub the ra'compensation awa of Cali. All roofs shall be inspected prior to any roofing material being
,
fornia' 1 !J ' installed. If a roof is installed without first obtaining an
Date/ � Applicant ( - inspection,I agree to remove all new materials for inspection.
NOT CE APPLIANT. If,after makinbecome
subject to theOWorrkenC Compensation provisionis of thei icate Labor Coda.yolu muaulothwiith comply 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 A0,
COVerI sytttoo b/ee cicla'ss"C"or better.//�� y��1
herebyauthorizepurpo a representatives of this city to enter upon the above-mentioned property for in- 1,/ry,YJ 16-If-46—
of
V�/� /'
herebon proposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against Ilabllltles,
)udgmeme,costs and expenses which may In any way accrue against said City In consequence
of the granting of this permit. —SIGNATUFfE OFAPPLICANT DATE
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