R-5355 (2) APPLICATION FOR CITY OF CUPERTINO
NUMBEPERMIR R- 53551
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
1115-3
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ II yes—I understand that a Class A
NAME root assembly is required.
NO ❑ Initial I.C.B.O.7F
ADDRESS EXISTING ROOF COVERING
PHONE O(y b r NUMBER OF EXISTING COVERINGS
CONTRALTO t
2 Q,(„�,•QJl TO BE REMOVED TO BE RETAINED
NAME
ADDRESSTYPE OF R OF VE N
clTva P EXISTING /O
�n a SO �
PHONE BUILT-UP ROOF
N4
LICENSE
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed underprovisions 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
affect. WOOD SHINGL El
License Cle v uc.N6 3 OTHER(SP IFY) O
Data Contractor actor
OWNER-the Conn OECLARAT N PROPOSED
hereby affirm that em exempt from the e: Any
License Law for the following reason. O
(Sec. uct, It Business and demolish,
or re Coda: Any city or county which requires a permit to
construct,alter,Improve,to file signed
or statem structure,prior to Ira Issuance,also requires the BUILT-UP ROO �y
eppllcent for such permit to Ills o Chaptstatement that he Is licensed pursuant m the provisions ,V9j' ��n of the Contractor's License Lew(Chapter 9(commencing with Section 7000)of Dar the 3 of the
Business and violation
oeasin of Cede)or that h,is exempt therefrom and the basis for the applicant
t0 ASPHALT SHINGLES
•
exemption,ltyof oft more
fhanioe hundred
oyany s($5applicant for e permit subjects the eppllcent to
e civil penalty of not mora then live hundratl tlollars(38001J:
C]1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKE$
the work,and the structure Is not intended or offered for sale(Sac.7044,Business and Pr0fes.
sions Code:The Contractor's License Law does not apply to an owner of property who builds or W�nS�lmr-LES
p
Improves thereon,and who does such work himself or through his own employees,provided that V
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 OTHERSPECIFY)
not build or Improve for purpose of Bele.).
^�•� ��[L�rp
❑I,ecowner 70the property, and Professions Code.
The Contractor's
License Law
construct �+RiIRD I.94T.REPORT NO.
the project(Sec.7044,Business end Professions Cotle:The and who con License Lew does not MIR
D1
to nt owner of property who builds or improves thereon,and who contracts for such projects
with a c m exempt u icon Se pursuant to me Contractor's License Lew. Cli fPPOWW 110FdONSTALLATION SPECS.
❑I em exempt under Sac. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: 00
I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, 06 Building M
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this Q / / J V
permit is Issued. / -7 4101 Seismic
have and will the performance
Worker's Compensation Insurance,as required by Section 3700's 111
t Labor Coda,for the performance of the work for which this permit is Issued.My Worker's
'Compenseb n Ins,.ranycna�wrrlar and Policy number are'. y// Total T.
Carrler� 7�'/-�^� Policy No. •� �� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.p
(This section need not be completed if the permit is for one hundred dollars($100)or less.) r, .0 O 1 -97
I certify that in the performance of the work far which this permit Is Issued,I shall not employ
any person any manner so as to become subjec o 7rkers•Cc enation Laws of can. All roofs shall be inspec ed prior to any roofing material being
lornie. installed. If a roof is installed without first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
subject to theOWorrkera Compensation ANT. 11,after proviso os of thellcele of Laborr Code,Exemption,
must forthwitbecome
h comply Applicant understands and will comply with all non point
with such provisions or this permit shalQbe 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 All roof cov ngs aclass" "or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes. /lC �� ,S
(We)agree to save.Indemnify and keep harmless the City a of Cupertino against liabilities. `4 ✓L7
ofjudgments,the gran rusts and expenses which may in any way accrue against said City In consequence
of megranungonnispermg. SIGNATURE APPLICANT ATE
• 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