R 5174 (2) PERMIT R_ 517 4 .
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
1B0 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
ji G t RESIDENTIAL COMMERCIAL OTHER
owNER's HAZARDOUS FIRE AREA
/) YES ❑ If yet—I understand that a Class A
NAME LU M roof assembly is required.
NO ❑ Initial I.C.B.O.q
ADDRESS .J�. EXISTING C/ F
PHONE (i ! NUMBER OF EXISTING COVERINGS
CONTRACTOR'S �/� /�
�aa S Kdo I If^ q TO BE REMOVED TO BE RETAINED
NAME l/��h� ':TY
ADDRESS (Jb Q (f �
TYPE OF R
CITYBZIP � ll
PHONE A BUILT-UP ROOF ❑
LICENSE
NUMBER (� ASPHALT SHINGLES ❑ l�
ICENSCONTRACTORS DECLARATION 196I hereby affirm that I em licensed
underuntler provisions of Chapter 8(commencing with Section WOOD SHAKES
7000)of Division/3 of m�Buel�e'ee and Professions Coda,and my license Is In full lone end
effect. - —_.�— � 7 Y WOOD SHINGLES ❑
License Close Lic.Number
Date Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which require.a permit to
construct.alter.Improve,demolish,or repair any structure,prior to Its issuance,atif.mquires the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor'.License Law(Chapter S(commencing with Section 7000)of Division 3 of the
• Business and Professions Coda)or that he la 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
e dvil penalty of not more than five hundred employees
dollars with
wag.):
❑tea and
er the structure
i not Int y Intended
oyeeeredfwages(Steel col,compensation,sand
Polf s. WOOD SHAKES
the work,antl the structure le not InsenLaw or offered pp sale now owner
of Business end Proles-
impr Cotle:The,an whod LicenseLewdoes not applytoanowneroproperty who builds or WOOD SHINGLES
Improves thereon,and who does such workhimselfforforthro ho his Own employees, mproetlthat ❑
suchimprovementswithin
oneyeare not completion,
leb n,or oHeretlforsale.It however,the enofbuilding pros ImprovementIsso '
not
or
prove for purpose
sal.owner-0ulltlerwill havethe burden of proving that he tlitl 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.License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who WWI;or Improves thereon,and who contracts for such projects {I
with a am exempt
licensed pursuant to the Contractors License Lew. PROVRE�MFGR. INSTALLATION SPECS.
❑1 em exempt untler Sec. ,B 8 P.C.for fele reason W
Owner DateATIO APP TON DA VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I reby affirm untler,penalty of perjury one of the following declaration;
K.blr
e end will maintain a Certlllcete of Consent to sell-Insure for Worker's Compensetlon, C� ' Buildinged for by Seolon 3700 clthe Labor Co defor the perform.nce of the work for which thiseeuetl.e and will malnteln Worker's Compensation Insurance,as required by Section 3700 of h LurCh/�N / r Seismic
theCode for a performance of the work for which this permit le issued.My Worker'sYJCoIon su ce carrier and Policy number are: I I ''..�� Total
Can Policy No.M&II', �� PERMIT AUTHORIZATION DATE
CE iFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.Cl ��
(This section need not be completed It the permit Is for one hundred dollars($100)or less)
I certify that In the performance of the work for which this permit Is Issued,I shall not em ley ll roofs shall be inspected prior to any roofing material being
any person In any manner so as to become subject to the Workers'Compensation Laws of�en- A
fornla. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTCE TO ecome
subject lt.the WorkereCCompensation pro�viafter sionis ofaihe Labor Code,you must fo thwlithou shoudccomply 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 relining to building construction,and All roof cover' to be class"C"Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property far In.
spectlon purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
of the gran costa and expenses which may In any way accrue against said City In consequence SIGNATURE OF APPLIC
• or me granting or rale permit. 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