R 5321 (2) APPLICATION FOR CITY OF CUPERTINO
NUMBIER R- 53 21
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
• WITHIN 130 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
-7 31
Ja. RESIDENTIAL COMMERCIAL OTHER
OWNER'S WARDOLIS FIRE AREA
VES ❑ If ye understand that a Class A
NAME assembly is requiredIf
Initial I.C.B.O.N
ADDRESS x �'� EXISTING ROOF COVERING
PHONE
NUMBER OF EXISTING COVERINGS '
�N
CONTRA R'S t
TO BE REMOVED E
NAME p
ADDRESS TYPE OF ROOF COVERI Gtf�
clTv a ZIPEXISTING
STING
PHONE `rd",L /�4 SAN se ps BUILT-UP ROOF ❑9
LICENSE
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am Ilcensed under provisions of Chapter B(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Bueineae and Professions Code,and my license Is In full force and
effect. WOOD SHINGLES ❑
License Clee Lie.Number
OTHER(SPECIFY) ❑
Date Contractor
OWNER-BUILDER LARATION PROPOSED
I hereby affirm that I am exempt from the Contractors License Law for the fallowing 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 toa file a signed statement that g it licensed pursuant to the provisions
• of the ss an Pro License Lew(Chapter h(commencing with Section 7000)of for the 3 of the
exemption
and Professions Code)or that he Is exempt therefrom and the baste for the applicant
to ASPHALT SHINGLES
axamppen.Any violation ofhSection five hundred
byany applicant for a permit subjects the eppllcent to
a civil penalty of not more man floe hundred dollars(h wage WOOD SHAKES PA
❑Irks owner structure
I not I my tended employeeswithas(Sec,their safe compensation,sand
Profes-
sions
s- ❑
she work,and the structure Is not Intended or offered for sale(Sec,7044, ropertes antl Proles-
Improvsth:The Contractor's oessucLicense Law orkhidoes not orthroghhisowneployees,proidy who edtatlds or WOODSHINGIF �p
Improves Thereon,and who does such work himself or through his own employees,or provided that rV ,p �� ❑
such Improvements are not intended or offered for sale.If,however,the building or Improvement f0 ry[��
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPIrQIrfY) L
not build or Improve for purpose of sale.). ,Jf-
01,as owner of the property,am exclusively contracting with licensed contractors to construct LUi ,
the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REP01"II IVOG
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFG R. INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE ., •-VALUATION PERMIT E
WORKERS COMPENSATION DECLARATION \
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 Workers Compensation,
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this / Lr 7
permit Is Issued. //J i�/ Se mic
❑t have and will the performance
Workers Compensation Insurance,to required by d.My 3700 of r V
the Leber Cotle,tar the pedormanca of the work for which this-pamiyrl9 ly uetl.My Workers Total
Compenaetl�n Ina rants corder an Po .y number eta: '.1T -5
cerraerFRlicyOM o.WORKE
CE � PERMITAUTHORI DATE
` RTIFICAT OF E%EMPTION FROM RS'
COMPENSATION INSURANCE N
(This section need not be completed it the permit is for one hundred dollen($100)00)o or less.)
1 certify that In the performance of the work for which this permit Is ji I shall not employ
any person in any manner so as to become subject to the Workers'Cc Pansatlon Laws of Cali. All roof.^shall be inspected prior to any roofing material being
fornia. „ installed. If a roof is installed without first obtaining an
Dela.� Applicant ction,I agree to remove all new materials for inspection.
NOTICE TO APPL CAI'T: II,seer making tris !tl to of Exempt) yo 61 Quad becom pplicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Cable,you must forthwith comp,
with such provisions or this permit shelf 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 relating to building construction,and A 00 overingsto ecl "C"or better.
hereby authorize representatives of this Cary to enter upon the above-mentioned property for in. /
spectlon purposes. r
(We)agree to savo,indemnify and keep harmless the City of Cupertino against liabilities,
judgments.Coate antl expenses which may in any way accrue against said City in consequence
of the granting of this permit. G TUBE F 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