R 5911 (2) APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 5 911
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS Nor STARTED
WITHIN 160 DAYS OF PERMIT ISSUANCE OR
1 B DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS` Ny• /q
RESIDERTIALU/ COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES 0 If yes-I understand that a Class A
NAME roof assembly is required.
NO Inigal I.C.B.O.#
ADDRESS —�� �^r� EXISTING ROOF COVERING
PHONE I NUMBER OF EXISTING COVERINGS I
CONTRACTOR'S
TO BE REMOV TO BE RETAINED
NAME P-Dil�k
ADDRESS -� 1 TYPE OF ROOF COVERING
CITY&ZIP111�0� L11f1: S�nA C,�Q
PHONEI�1 ��f I�y�c�0 BUILT-UP ROOFLICENSE ❑
2lo`Z..
NUMBER to ASPHALT SHINGLES `W
LICENSED CONTRACTORS DECLARATION f
hereby i affirm that em Business
antler Professions
of Chapter 9(commencing with reaction WOOD SHAKES ❑
7000)of Division 3 of the Business entl Profeealons Cotle,and my license le In lull torte and
affect.
b -L WOOD SHINGLES ❑
Licens/eClasa - Lie.Number ,
Date s� ,D Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt tram the Contractor's License Law for the following reason.
(Sac.7031.5'Business and Professions Cotle: 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 ❑
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions
of the Contractor'.License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he la exempt therefrom and the basis for the alleged ASPHALT SHINGLES ❑
exemption.Any violation of Section 7031.5 by any applicant fora permit subjects the applicant to
a civil penalty of not more than five hundred ofollars($500).):
E3 1,as owner f the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not intended or offered for sale(Sec.7044,Business and Praise.
alone Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees, rovlded that Elsuch Improvements are not Intended or offered for sale.It,however,the building or Pmprovement
Is sold within one year of completion,the owner-butdar will have the burden of proving that he did OTHER(SPECIFY) ❑ U {,
not build or Improve for purpose of sale.). J1
1,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Lew tloea not pp��PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or improves thereon,and who contracts for such projects #— I
with a contractor(s)licensed pursuant to the Contractor's License Law, ROVE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B&P.C.for this reason j
Owner Date / A`PI!I1Lr6AA0WATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION Cin'
I hereby affirm under penalty of perjury one of the following declaration: 7 t-
❑1 have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, Building tar__
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this // 9
permit lave and GSL Seismic O
❑ have entl will the performance
Workerrmanc'e Compensation the work
Insurance,as required Is
by d,My
3700 0l IJL�
.the Leber Code,for the pertormence of the work for which this permit Is laeuetl,My Workefe Q
CompenaeaffF^In uranee ca{r�rI end Polley number are: ^7 Total
carrier J'"A�� /—N'vtb Policy Nob_ 2n DY PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0 t ® /J
(This section need not be completed If the permit r one tlretl tlollera($100)or lees.) `(/xk
I certify that In the performance of the work for I aper It le laeued,I shell not employ
any person In any manner so as to become su he Wart s'Compensation Lews of Oali. All roofs shall be inspected prior to any roofing material being
fornla. installed. If a root is installed without first obtaining an
oataXLJ?1� A inspection,I agree to remove all new materials for inspection.
subject to NOTICEheWOPkereCecome
Compensatle°n v Dole CtheiLeb-tooatso�Cotle,yolumaust forthwshoutitlthbcomply Applicant u erste and will comply with all non point
with such provisions or this permit she de ed revoked. Source re I ti
I certify that I have read this application tl 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 All rO O}I ngs to C Or bettl
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
ep ctionWe)agree to
(Wen°pros to save,expenses
and keep harmless the City ai Cupertino Ci against habitee e,
of the gran costs and expenses which may In any way accrue against 6eltl City In consequence
of the granting of this permit. I ATUJK OF APPLICAftr 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