R 5965 (2) PERMIT R_ 5965
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT _ (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
-94 WITHIN 180 DAYS OF PERMIT ISSUANCE OR
• 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
NE/R'$� �x HAZARDOUS FIRE AREA
[ / 1 YES E] If yes—I understand that a Class A
NAM ��SN Q�S YES
roof assembly is required.
NO ❑ Initial I.C.B.O.N
ADDRESS;FA /f EXISTING ROOF COVERING
PHONE "/{�' D NUMBER OF EXISTING COVERINGS I
CONTR TOR'S �/ /
NAM Z yC • TO BE REMOVED—/ TO BE RETAINED
ADDRESS I�/�� /��/ S /? � 90 2) TYPE OF ROOF COVERING
CITY 8 ZI / / �j 2 / cJ EXISTING
PHONE T._3/1L' �C,1A 3 BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALTSHINGLES ❑
LICENSED CONTRACTORS DECLARATION -
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES lf`R+I
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect, /(A/"-p' QSqq ��/ ,�/!��& WOOD SHINGLES ❑
License Class . 9 Uc.Number L __
Date Contractor H (SPECIFY) ❑
OWNER-BUILDER DECLARATION P D
I hereby affirm that I am exempt from the Contractor's License Law for the following 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 to file a signed statement that he le licensed pu rauant to the provisions
of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Dlvlslon 3 of the '
• Business and Professions Code)or)hat 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 s�
a civil penalty of not more than five hundred dollars(8500).): P fl
01,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 Profes.
dons Code;The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES JUL 2(vQ AAI
Improves thereon,and who does such work himself or through his own employees,provided that Npr�
such improvements are not intended or offered for sale.If,however,the building or Improvement II��11
IS Sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) CITY Ur iJ
not build or Improve for purpose of sale.). VVn Lf t III[:]I,as owner of the property,am exclusively contracting with licensed contractors to construct VV
the project(Sec,7044,Business and Professions Code:The Contractors 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 aam ex licensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exemptmpt under Sec. ,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: 1 7
❑1 have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is head. Q Seismic CI
❑ have antl will maintain Works' Compensation Insurence,es required by Section 3700 01 ,(�
.the Labor ode,for the perform. a of the work for which this permit Is Issued.My Worker's cOr D D
Compo ion Insuragce carni r of numb r ere: - Total O
1
car r IP.IicyNo.� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
fThle section need not be completed If the permit Is fon one hundred dollars($100)or less.) , r"'�
I certify that in the performance of the work for which this permit Is issued,1 shall not employ ^, 1j 40 !/
any person in any manner so as to become subject to the Workers'Compensation Laws of Cali. All roofs shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
ecome
subject T1to the Worrkere C mpelnseto proviCE TO APPLANT: 1,after sionis of thelLabor Code,you musths Certifcate of Exemption, t fonhwlithshoudb amply Applicant understands and will comply with all non point
with such provisions on this permit shalibe deemed revoked. Source regulations.
I certify that I have read this application and state that the above Information Is correct.l agreeto iq
hereby uthorzereyenticounty ordinances antlstate teruon thelatinglobulldinedpropertly for
All root COVQ[ gS to be (i��Or better.
hereby authorize representatives of this city to enter upon the above-menlloned property for In-
sp(Wit)
purposes.
)
(We)agree to neve,expenses
and keep harmless me City of Cupertino y Inagainstcon liabilities,
ofjudgments,the gran costs and expenses which may In any way accrue against said Clry In consequence
of the granting of permit, SIG RE OF APPLICANT DATE
• PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE )NSP. 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 -