R 5192 (2) PERMIT R_ 519 2
APPLICATION FOR CITY OF CUPERTINO NUMBER
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 �J
c rJ532 t ,_h(��
�Dlq �uP
RESIDENTIAL
COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAMEn roof assembly is required.
NO� � ^'l(\T/J„ ❑ Initial C.B.O.M
ADDRESS2 / l � 2f I EXISTING ROOF COVERING
- � 2
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
p TO BE REMOVED ;%O,-I: TO BE RETAINED
NAME
• ADDRESS TYPE OF ROOF COVERING
CITY&ZIP
EXISTING
PHONE BUILT-UP ROOFLICENSE
❑
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby allirm that I am licensed under provisions of Chapter 9(commencing with Seclion WOOD SHAKES
7000)or
Division 3 of the Business and Professions Code,and my license Is In lull force and
effect.
WOOD SHINGLES ❑
License Claes LIc.Number
Date Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
hereby affirm inel am exempt from the a: Any
or roue Lew for the folrequires
a reason.
cons.70315,Business and Profedemolish.
or rep Coda: Any city or county which re,also a permit to
applicant ortsu Improve,to file signed
n d statement
any menstructure.Is licenseor to Issuance,to the p owslon° BUILT-UP ROOF
of the Contractors
for such permit a Ills a elgned r 9(commencing
he le h Sectio pursuant to the provisions
of the ss an c Professions
r f License Lew(Chaplet aisexpt with Section 7000)of for the 3 of theBusine
•
exemption
end violation of Soca)or that he is exempt therefrom and the heals far the applicant
to ASPHALT SHINGLES ❑
exemption.Any violation of than
Section 7031.5 by any applicant for a permit subjects the appllcent to
e civil penalty of not more than five hundred dollars($500)J:
C]1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not intended or offered for sale(Sec.7044,Business and Profen
slons Code:The Contractor's License Lew does not apply to an owner of property who builds or WOOD SHINGLES
improve$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) •,�
not build or Improve for purpose of sale.).
❑I,as owner of the property,am 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 contractons)licensed pursuant to the Contractor's License Law. PROVIDE MFGR. INSTALLATION SPECS.
❑ am empl u r Sec. ,B 8 P.C.for this reason
o ^� D 'WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: p$
❑Ihaveand will maintain a of thel Lab r Consent sell-insure for Worker's Compensation, fr ® Building
pe provided for by Section 3700 of the Labor Code,for the performance of the work for welch this
permit is Issued. r SA Seismic
❑I hero and will themaintain Worker's Compensation Insurance,as required by Section Worker's
's f/ �y
the labor Code,for the performance of the work for which this permit Is Issued.My Worker'$ ^/ 'y['1 Total
Compensation Insurance settler and Policy number are: N v33
Carrier Policy No. P Tj ORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑ AO
(This section need not be completed If the permit is for one hundred dollars($100)or less.) (/
I certify that In the performance of the work hich this permit le Issued.I shall not employ
any person In any manner so as to beco the re'Compeneetlon Laws of Cell- All rDOfS S II inspected prior to any roofing material being
1°`nle. I r
„ installed. If a roof is installed without first obtaining an
Date Appllcan inspection,I agree to remove all new materials for inspection.
subject ct to the Worrkers'CompeOTICE TO APPLICANP. f.after ne ti n provisions of theLaborCode,cats of you ,you should become Applicant understands and will comply with all non point
you must forthwith comply P Y
with such provisions hav r this permit shati n deemed that the Source regulations.
certify ThalIhave reatlthis ounapplicationand dsathattheabove Informationbuilding Is correct, agree
to hereby author with all cityandBounty ordinances and terntate on threlatingbove- eating dpro property
and All ro overings to be class"C”or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
specllon purposes.
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may In any way accrue against said City In consequence
. of the granting of this permit. 'trzSIG URE OF 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