R-5311 (2)L-1
•
-Z
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R— 5 311
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
—5yyy �/' q
5 S f 6lg Q
/
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RESIDENTIAL COMMERCIAL OTHER
OWNER'g`_1
HAZARDOUS FIRE AREA
` ,
i //Z I/710 V^LI��
VES ❑ If yes -s Iunderstand ClassA
NAME 000/// ('i I'yvC,y `r`I
ire,
roof assembly Is required.
8 �2/�%�G� �$� ew
- EXISTING ROOF COVERING
ADDRESS -77,} Y ✓
NUMBER OF EXISTING COVERINGS /
rn" 7
PHONE
TO BE REMOVED fill TO BE RETAINED
CONTRACTOR'
'
NAME
/J
ADDRESS -4— /ti ✓J`LO�
TY F V IN
CITY &ZIP /J �/���T CJG V
EXISTING
PHONE
BUILT-UP ROOF
CENSE
NUMBER
ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section
WOOD SHAKES
7000) of Division 3 of the Business and Professions Code, and my license Is In full force and
effect.
WOOD SHINGLES
License Class Lic. Number
OTHER (SPECIF�S) A I D ❑
Date Contractor
OWNER -BUILDER DECLARATION
PROPOSED
I hereby affirm that l 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
-
24 �C�
construct, alter, Improve, demolish, or repair any structure, prior to Its Issuance, also requires the
BUILT-UP ROJVN ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
_
of the Contractor's License Lew (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he Is therefrom the basis for the
rrII�f I r `I�'I)VU
exempt and alleged
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 (S500t):
ASPHALTgH%Cklig�rCll
f e
❑I, as owner of the property, or my employees with wages as their sole compensation, will do
WOOD SHAKES El/
the work, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Profes-
sions Code: The Contractor's License Law does not apply to an owner of property who bunds 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. II, 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. 7(t44, Business and Professions Code: The Contractor's License Lew 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 Contractors License Law,
PROVIDE MFGR. INSTALLATION SPECS.
❑ I am exempt under Se ,B 8 P. C. for this reason
n -••r Data
APPLICATION DATE
VALUATION
PERMIT FEE
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 sell -Insure for Worker's Compensation,
as for by Section 3700 of the Labor Code, for the the for this
/
Building
provided performance of work which
permit is Issued.
❑ have and will Worker's Compensation Insurance, as required Is by 3700
^.
I�
L �l�o (/,O
Seismic
the pelrf
the wokfor i d. My 's
Co Labor Coda, for the performance of the work for which this permit Is issued. My Worker's
'Compensation
Total
Insurance carrier and Policy number are:
Carrier Policy No.
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 S1 00) or lass.)
I certify that in the performance of the work for which this permit Is issued, I shall not employ
Allroofsshall be inspected prior to any roofing material being
any person In any manner so as to become subject to the Workers' Compensation Laws of Cali-
fonds,
installed. If a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE TO ecome
subject to the WAPPLICANT:
kers' C Compensation tion provi, after sions of the this lLabor Code, cate of you mustforthwith ldbcomplyAApicannderstands
and will comply with all non point
with such provisions or this permit shelfbe deemed revoked.
JailorI
certify that I have read this application and state that the above Information is correct. I agreeto
comply with all city and county ordinances end state laws relating to building construction,antlof
tO be Cla r Iter.hereby
authorize represenletivea of this city to soler upon the above-menlionetl property for dmherebon purposes.(We)
agree to save, Indemnify antl keep harmless the City of Cupertino against liabilities, ..Ad
judgments, casts and expenses which may In any way accrue against said City In consequence
SIGNA UR FAP LICANT 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 _ _ _