R 5319 (2) APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 5 319
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
•
IN DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS /
/ J/
SIDENTIAL COMMERCIAL OTHER
W HAZARDOUS FIRE AREA
NAME YES ❑ II yes—I untleatand that a Class A
roof assembly is required.
NO L Initial LC.B.O.M
ADDRESS "� EXISTING ROOF COVERING
•T
PHONE
NUMBER OF EXISTING COVERINGS
CONTRA R'S
NAME TO BE REMOVED TO BE RETAINED
AD 'S 61 TYPE OF ROOF COVERING
CITY 8 zIP7S.C�'L� . /�IdS 5t
S.s dose �� �js/aG EXISTING
PHONE BUILT-UP ROOF ❑ ,:�
NIUMBER / ASPHALT SHINGLES 4l Co-*4,
LIC SED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ❑ /@ Gr^^//�
7000)of Divlalon 3 of the Business and Professions Coda,and my license Is In full force and V yCTI
Lieffen 7C WOOD SHINGLES ❑ �/g
License Clesa It.Number 9)
OTHER(SPECIFY) ❑
Data �- contractor 0
NER-BUILDERR N PROPOSED
I hereby affirm that I am exempt from the Donato or'&LIc°nea Lew for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to en y
construct,alter,improve,demolish,or repairanystructure,prior to Its Issuance,also requires the BUILT-UP ROOF Npp� d R�t
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 Cade)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINgtcal,�r��,,'"
/-
exemptlon.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to (xUrtry V
a civil penalty of not more than five hundred dollars($500).): WOOD SHAKES
E)1.as owner of the property,or my employees with wages as their sole compensation,will do ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes-
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,provided that ❑
such Improvements are not Intended or offered for sale.if,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) El
build or Improve for purpose of sale.).
❑I,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(&)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 em exempt under Sac. ,S$P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT F
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, r Build!
O
as provided for by Section 3700 of the Labor Coda,for the performance of the work for which this /^/ C
permit Is Issued. ` C✓ �+Q^
❑Ihaveantl will maintain Worker' o pensation l,ksurance, req d S von3700o1 I7 �,,L./. Seismic
_the Labor Code,for the erformano f work for wh I tl.M Worker's /
Compensetl n Ina entree artier an o n gapi� y Total
Carrier Y//J,yr'. Policy No. PERMIT AUTHORIZATION DATE
CE TIFICATE EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.
(This section need not be completed If the permit Is for ono noted dollars($100)or less.) O U
I certify that In the performance of the work to hlch 1hl p r It Is Issued,I shall not
any person In any manner so as to become sub to the or a'C mpensatlon Lew
°`nia, roofR shall be inspected prior to any roofing material being
stalled. If a roof is installed without first obtaining an
Date 7 Applicant A spection.I agree to remove all new materials for inspection.
subject to the wm er$'Compensation fter provisi nis lir Labor Code,yoiu mustuforthwhouith compro. Applicant understands and will comply with all non point
with such provisions or this permit shalPbe deemed revoked. SO regulations.
1 certify that I have read this application and state(hat the above Information is correct.I agree ^^��
to comply with all city and county ordinances and state law.raising to building construction,and Iroo Coverings to Is 5„G"Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spection purposes. L
(We)agree to as,.,indemnity and keep harmless the Clty of Cupertino against liabilities,
' of the which may in any way accrue against as
e g anting of this permit. id CIN In wnsequence SIGNATURE OF/ ICANT 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
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