R-5440 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBERR_ 5440
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
WI180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S , n n HAZARDOUS FIRE AREA
/ yy. YES E] If yes-I understand that a Class A
NAME rrr"'""""""""����� `7774�� roof assembly is required.
C� NO Initial I.C.B.O.N
ADDRESS dP - EXISTING ROOF COVERING
PHONE
d—J NUMBER OF EXISTING COVERINGS
CONTRACTOR'S /y l
NAME
�/L/l /I(w " TO BE REMOVED TO BE RETAINED
ADDRESS 5 j, J // (J ,� TYPE OF ROOF COVERING
CITY&zIP52 !.�- �C ravr EXISTING
PHONE `% 65 -73
0y BUILT-UP ROOF ❑
NIUMBER 65 -7 3 - ASPHALT SHINGLES ❑ � 7��
LICENSED CONTRACTORS DECLARATION
I hereby affirm that em Ilcensetl under provisions of Chapter g(commencing with Section WOOD SHAKES V/
7000)of Division 3 of the Business and Professions Code,and my license is In full force and
effect' x� WOOD SHINGLES
m ❑ ��j
License Class Lie.Nuber 10
Data lU G contractor OTHER(SPECIFY)P A I D ❑ —
OWNER-BUILDER DECLARATION PROPOSED
hereby affirm Bu Chet am exempt from the e: Any
License Lew for the following reason. MT _ L Y_�
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to (V��� 1U11L.IPI
constant,eller,Improve,demolish,signed
or repair any structure,prior to Its issuance,also requires the BUILT-UP ROO
applicant for each permit to Ills a signed statement that g it licensed pursuant to the provisions ��,�1�r'�`�.
of the Contractor's License Lew(Chapter 9(commencing with Section]000)of Division 3 of the I ( UUrtH Ill I /1
Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALTS I GL $
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of not more than five hundred dollars($5001 -1.-
❑ WOOD SHAKES 1,as owner 0l the property,or my employees with wages as their sate compensation,will do ❑ �� /� n
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes. ,p-GLI/
sions Code: The Contractor's License Law does not apply to an owner of property who buildsor WOOD SHINGLES ❑
improves thereon,and who does such work himself or through his own employees,provided thal
such improvements are not Intended or offered for sale.It,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,em 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 coniractor(s)licensed pursuant to the Contractor's License Law, PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,a&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I herebyhave
and under penalty of perjury one of the following declaration:
for Wo /
❑ have antl will maintain a of the
of Consent to self-Insure for Worker's Compensation,this /a BUIIdmg1
as provided for by Section 3700 of lha Labor Cotle,for the performance of the work for which this /
per Is issued. {t /Oj V ry ` Seismic ��
have and will maintain Workers Compensation Insurance,as required by Section 3700 of
t Le r Code,for the performance of the work for which this permit is issued.My Worker's
Compensation n ren a ctfrre7r end Policy number are: Total
Carrier T u^'vle� Policy N`3 ��3b -qb PERMIT AUTHORIZATION AT
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.]
(This section need not be completed if the permit is for one hundred dollar(5/00)or less.)
I certify that In the performance of the work for which this permit is issued shall not employ
any person In any manner so as to become sucedto t �ydrv, s compo aeon Laws of call- All roofs shall be inspected prior to any rooting marial bel
torn'.. installed. If a root is installed without first obtaining an
Data4!66 Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Cerfilicaffi of Exemption,you should became Applicant understands and will comply with all non dint
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP P Y P
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.'agree
to hereby
a with all rep and se counry of this cos and ter u on the
bove- anti n d property
and All roof CO�l�rl e be claSfsvC"Of better. /�
hereby authorize representatives of this city to enter upon the above-mentlonetl property far in. }(rJi�)/ J(�J�y�J`
apache)purposes. ,a
(We)agree s save, indemnity and keep harmless the City of Cupertino against liabilities, 6 /
ofjudgme
the grnts,an costa and expenses which may In any way accrue against said City Inconsequence
of the granting of this permit. SIGNATOR F APPLICANT 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY