R-5562 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBERR_ 5562
INSPECTION DIVISION PERMIT EXPIRATION
REROOFPERMIT (406)777-3226 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
' 180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
22 Q V RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
C � / YES ❑ If yeas understand That. Class A
NAME \ If y s-I u assembly is stand that
q NO ❑ Initial I.C.B.O.If
ADDRESS 2 Z � � J�$j Pel/�'t,Yl ,J�(� , EXISTING ROOF COVERING
PHONE !3 NUMBER OF EXISTING COVERINGS I
CONTRACTOR'S y�
NAME
' l•/� ` FX__ /�r/iy � TO BE REMOVED--L—TO BE RETAINED
!/ Yi �'�+� L.
of ADDRESS �� � n ) f' _ J TY F ROOF C V
CITY&ZIP
71-L EXISTING
PHONE BUILT-UP ROOF ❑ 9 3/
LICENSE 'S ASPHALT SHINGLES Y
NUMBER
LICENSED CONTRALTO S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES El7000)of Division 3 of the Business and Professions Code,and my license Is in full force and
effect.
License Close Llc.Number
LQS`9 WOOD SHINGLES ❑
Datacontractor OTHER(SPECIFY) ❑'
OWNER-BUILDER DE RATION PROPOSED
I hereby affirm that I em exempt from the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Professions Coda: 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 provlsione
of the Contractors License Lew(Chapter 9(commencing with Section 7000)of Division 3 of iha
• Business and Professions 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($500).):
E]1,as owner at the property,or my employees with wages as their sole compensation,will do WOOD SHAKES E]the work,and the structure is not Intended or offered for bale(Sec.7044,Business and Profes.
sions Code:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES El
thereon,and who tloes 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 tloes 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 contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
-11 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
,_permit Issued.
V $elsmlC
have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
• the Labor Coda,for the performance of the work for which this permit Is Issued.My Worker's
Cr�npensetion Insurance carrierPolicy number are: Total
CarrierPolicy No. YL 77 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' �Tr
COMPENSATION INSURANCE N.C.❑ �1`f
(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 for which this permit Is Issued,I shall not employ
Torn--
any person in any manner so as to become subject to the Workers'Compensation taws of Calm All roofs shall be inspected prior to any roofing material being
Ionia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTsubject lt.the WorkeCE TO r
s'Co peinsatio provimakinsionis of theicate of Labor Code,you mustufothwlitlh comply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. Source r gulatlons.
I certify that I have read this application and state that the above Information Is correct.I spree
to comply with all city and county ordinances and state laws relating to building construction,and All roof v ingsI BC SS°C"Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
' ofjudgments,the gran costa and expenses which may In any way accrue against sold City In consequence SIGN U APPL ATE
of the granting of this permit.
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