R 5320 (2) PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 5320
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
X310
,4), 0.c1
RESIDENTIAL COMMERCIAL OTHER
wN R'9 HAZARDOUS FIRE AREA
NAME f -� //(__.('� �Q�"f��� t YES ❑ ,tl yeas assundembly
req iret. Class A
Ey/root assemhl is required.
NO Initial I.C.B.O.#
ADDRESS�06_gA9J EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS 1
CONTRACWRS I
TO BE REMOVED \ TO BE RETAINED
NAME
ADDRESS �, h T TYPE OF ROOF COVERING
CITY&ZIP
�e5e doq 5-- a6 EXISTING
PHONE LICENSE�41 BUILT-UP ROOF ❑
NUMBER / ASPHALT SHINGLES
LICENSM CONTRACTORS DECLARATION /�
I hereby affirm that I am licensed untler provisions o1 Chapter g(commencing with Section WOOD SHAKES • A O ® ❑
7000)of Division 3 of the Business and Professions Code,and my license Is in lull force and
effect.
IS WOOD SHINAk pS ❑
License Class Lic.Number
ctor //ff77
_ OTHER(Alt��FhY) CD ❑
Data "� Contra
OWNERAIIILDERO R N PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason. NU
(Sec.7031.5,Business and Professions Code: Any cfly or county which requires a permit to
applicant
acntfor such prove,ermit tedesigned repair any
menstructure,prior Issuance,alsto
herovisithe BUILT-UP ROOF
applicant for such permit to lite demolish.signed statement that he Is for to It tl pursuant to o requires sl the
• of the Contractor's License Law(Chapter 8(commencing with Section 7000)of Division 3 of the
Business and Profeselons 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 then five hundred tloilars($500).):
01,as owner of 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 Proles.
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES // El
thereon,and who does such work himself or through his own employees,provided that
such improvements are not Intended or offered for sale.If,however,the building or Improvement
Is sold within one year of completion,the owner-buider 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(Sac.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 contractogs)licensed pursuant to the Contractors License Law. PROVIDE MFGR. INSTALLATION SPECS.
01 am exempt under Sec. ,B&P.C.for this reason
Owner
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
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 Workers Compensation, BUII(
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit Is Issued. . � $els I
❑ have and will maintain Worker's 1the work
for Insurance,as required by Section 3700 0l
the Labor ad 1.for the performance o the work for which This e e issued.My Worker's Total
Compensat urance carrier Ir cy umbepare: /
Carrier IlcyNo. n,—.cPERMIT AUTHORIZATION DATE
CERTIFICAA OF %EMPTI FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed If the permit is for one hundred dollars($100)Or lase.) C�JY�7wJA`rli,K/
I certify that in the performance of the work which this permit Is issued,I shall n e ploy
any person in any manner so as to become I je t to the or ra' pensation L ail. All roofs shall be inspected prior to any roofing material being
fornix. `��}� 1 installed. If a roof is installed without first obtaining an
Dare /— J L/ Appucam 'nspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICA,1r: If,after melon t a Ilcete of Exemption,you shout
subject to the Workers'Compensation provisia s al t eLobar Code,you must forthwith com Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. sour regulations.
I certify that I have read this application and state that the above Information la correct.I e0ree
to comply with all city and county ordinances and state laws relating to builtling constructionantl A foot OVerlOgS ss"C"or better.
hereby authorize representatives of this city to enter upon the above-mendonatl property for In
spechon purposes. *OF
(We)agree to save,Indemnify and keep harmless the City of Cupertino against Ilaolliifaof the gran,a B is end ppeermitsea which may In any way accrue against aeld Clry I. & ATURE ANT DATE
of the !astir of this and
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