R 5865 (2) 1
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 5865
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
'/
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
NAME 4a"r�>/ YES ❑ If yes—I understand that a Class A
roof assembly is required.
NO ❑ Initial I.C.B.O.#
ADDRESS �`Z./C� �✓�G f%iG EXISTING ROOF COVERING
PHONE 7/ - Y%9J NUMBER OF EXISTING COVERINGS
CONTRACTOR'S - '
.2 �G GX�ti TO BE REMOVED TO BE RETAINED
NAME
ADDRESS TYPE OF ROOF COVE:;
CITY&ZIP � �G. "e"1bs 9V r1�3
EXISTING
PHONE b !J's _ 'if 4J BUILT-UP ROOF.
LICENSE ❑ C�
NUMBER Z� - ASPHALTSHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby 9nlrm that I em licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
enact. C / WOOD SHINGLES
❑
License Cieae Llc.Number 7Z7,l
Date 3(`17— Sr/ Contractor �- G o icy OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED -
1 hereby affirm that I am exempt from the Contractors Ucenae Law for the following reason.
IS
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 Contractors License Lew(Chapter 9(commencing with Section 7000)of Division 3 of the O
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 subject&the applicant to
a civil penalty of not more than five hundred dollars($500)): A
01.as owner of the property,or my employees with wages as their sols compensation,will do WOOD SHAKES ❑ W
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Proles.
alar Coiiesthereo ,an who
Ucenae Lew does not apply toanOwner of property who builds or WOOD SHINGLES p�f� 1ry AlIls46
Improves thereon,and who dose such work himself or through his awn employees,Improvement
ed that MIR ! AMID
such Improvements are not completion,
leb n,or offered for leer.If,however,the building or Improvement
not bullIs sold thinor provne e r of for purpose
sale.).
Owner-bulltlerwlll have the burden of proving that hedid OTHER(SPECIFY) �x �I
notb1,aor Improveterpurpose of eel&). CIR <✓ -YCAI11V
❑I,ecowner tithe property, an exclusivelycontractingCoccdngwile licensedcontractorsLicense Law
constructdoes
onot
the project(See.7044,Business and Professions Improv Code:The and who
Ucenae Lew doesnot PROVIDE I.C.B.O.REPORT NO.
apply to h a c contractor(s)
property who builds ore Contrathereon,end who contracts for each projects
weEjI antexempt neer Se pursuant to the Contractors scenes Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑I em exempt under Sec. ,B 8 P.C.for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby off rm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, BUllding
as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which this
permit is ued. G
aveand will maintain Worker's Compensation Insurance,as required by Section 3700 of 4�/1— / S O� OO Seismic
the Labor tion I for the performance of the work for which this permit Is Issued.My Worker's Total
'Compensation Insurance carrier and /oflay number are: f
Carrier 57�?'� I•y✓s PoncyNo.4711# /, -97 PERMIT AUTHORIZATIODATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE I N
(This section need not be completed It the permit Is for one hundred dollars($100)00)or less.)
I certify that In the performance of the work for which this permit Is issued,I shall not em Ioy
any person in any manner so as to become subject to the Workers'Compensation Laws of lPair. All roofs s I be inspected prior to any roofing material being
forma. installed. If a roof is installed without first obtaining an
Data Applicant inspection,I agree to remove all new m erials for inspection.
NOTICE TO APPLICANT: If,after subject to the Workers'Compensation provialonis of the 11Labocate rCode,Exemption,
olu must forthwilthacomecomply Applicant understands and Dimply with all non point
with such provisions or this permit shallPbe deemed revoked. Source r tions.
I certify that I have reed this application and state that the above Information Is correct.I agree
to comply with all city and county ordinances and state law&relating to building construction,and AI Of be Class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
sppurposes.
(We) / 7
(We)agree to save,expenses
and keep harmless the Clry of Cupertino y n con liabilities, �G Y
7utlgments,conte and expenses which may In any way accrue against said City In consoquence
of tee grenibg of iMe permit. SIGNATURE 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