R 5318 (2) APPLICATION FOR clrY of cuPl=_arlNo
NUMBER PERMIT
R- 5318
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
' 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
-7312
ENTIAL COMMERCIAL OTHER
w s HAZARDOUS FIRE AREA
/ � LN_M� /N/ VES ❑ / If yes—I understand that a Class A
NAME f �.� L'CGlV( ' D� //G 6 y L�1/ roof assembly is required.
'� NO Initial I.C,B.O.k
ADDRESS—� EXISTING ROOF COVERING
x 1 .
PHONE NUMBER OF EXISTING COVERINGS
CONTRA R'S
r
NAME TO BE REMOVED � - TO BE RETAINED
ADDRESS �.� TYPE OF ROOF COVERING
CITY&ZIP EXISTING
sem✓dose Gp
PHONE /1LICENSE / I c BUILT-UP ROOF
NUMBER ASPHALT SHINGLE'
AID
CEN D CONTMCTOR5 DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 9(coma ing with Section WOOD SHAKEEf ❑
7000)of Division 3 of the Business and Professions Code,and my license la In full force and rV d
effect. /w/ Q
License Clasfl,�,"��' C.Numaer V 9 WOOD SHIA�Cp�FL�
Date� contractor OTHER(SPECIFY) L`rrHP�jyU ❑
OWNER-BUILDER E RATI 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 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 Professlons 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 than five hundred dollars($600).): WOOD SHAKES
El I,as owner of the property,or my employees with wages as their sole compensation,will do
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profee-
slonsCode:The Contractors 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,provided that
such Improvements are not Intended or offered for sale.If,however,the building or Improvement
Is cold 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 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 contractor(s)licensed pursuant to the Contractor's License Law, PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,e&P.C.for this reason
Owner Dale
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FE
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, BUI I SI
ea provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit la tl. /�/Si7/ Seism
eve and will maintain Workers Compeneetlon Insurance,ae re a pl
the Labor Code,for ins pedormence f the work fpr which Ihle d y orkers rn
the Labor
C n Ina a carrier a Ilcy number r 1 r�`--'�- Total
Cerner FRff.yOMNo.� PERMIT AUTHORIZATION DATE
CE IFIC OF EXEMPTION FROM WOR RS'
COMPENSATION INSURANCE N.C.
(This section need not be compteted If the permit Is for one hundred dollars($100)or lea
certify that In the performance of the work which Ihls pef It le lesueq shell t an
Is
forms
in any manner so Be to become su e 1 to Ina 1 l !k s'ComPenealIon L e of ) All roofs shall be inspected prior to any roofing material being
in stalled. If a roof is installed without first obtaining an
Date Applicant nspection,I agree to remove all new materials for inspection.
N icE TOTO A after making I Cert ate of Ptlon.You should e n
subject to the Workers'Compensation provislone of the Labor Code,you must forthwith comp All
understands and will comply with all non point
with such provisions or this permit shall be deemed revoked SO a regulations. -
I certify that I have reed this application and state that the above Information le correct,I agree
to comply with all city and county ordinances and state laws relating to building construction.and A roD coverings to be Cl "C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes.
(We)agree to save,Indomnify and keep harmless the City of Cupertino against liabilities, /s
judgments,costa and expenses which may In any way accrue against Bald City In consequence
• of the granting at this permg, URE 0 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY