R 5781 (2) PERMIT R_ 5781
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
RESIDENTIAL COMMERCIAL OTHER
OWNERSHAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME L/C/ /r/ W1'I.GL/ roof assembly.is required.
i—_ NO ❑ " Initial LC.B.O.#
ADDRESS '-V"k�/� EXISTING ROOF COV/EKING
PHONE • !O S Z- NUMBER OF EXISTING COVERINGS
CONTRAS
TO BE REMOVED , TO BE RETAINED '
NAME
ADDRESS y�� 54a. �►'I d /7 TYPE OF ROOF COVERING
an s zlP a r,—T5{ ,rS i EXISTING
PHONe 5/2-3 —G .3 7 3 BUILT-UP ROOF
LICENSEAlNOO - ASPHALT SHINGLES ❑
a
LICENSED CONTRACTORS DECLARATION ❑ /O
I hereby affirm that emlicensedsssunder Professions
lone of Chapter y(commencing with reaction WOOD SHAKES `
7000)of Dlvlelon 3 0l the Business and Profoeslone Code,and my license Is In full loroe and
effect.
License Claes Lie.Number Q0 WOOD SHINGLES
Date Contrecto
1252 5P OTHER(SPECIFY) ❑
OWNER-BUILDER DEC TION PROPOSED
I hereby affirm that I am exempt from the Contractors 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 is licensed pursuant to the provisions
of the Contractor's License Law(Chapter g• (commencing with Section 7000)of Dlvlelon 3 0l the 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).1: WOAD SHAKES
❑Ir as owner structure
Is not I tendedmy employees wit ecomEast�I a and 'I o A IK
the work,and the structure le not Intended or offs or agile IS 4, rop@ e. end r �s1/
alone Code: The Contractors License Lew does n ty to al playa who b r WOOD SHINGLES
Improves Thereon,and who does such work himseedfor ouoh own mplaye or prov0 t ❑ q,�q
such Improvements are not Intended or offered for however,the building or o
Is sold within one year of completion,the owner-bull Ihave �uraer5 at OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.). Sjt6 11 J 1.7
❑l,as owner of the property,am axclusively cool Ing wI111 Rdensed contractors to con c nn c�(�
the project(See.7044,Business and Prole.slonoC :The Contractors License Lew does no PROVIDE I.C.B.O.REPORT NO. G� x7 s1/
apply to an owner of property who builds or improves reon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contmc r'e License Law.
I am exempt under Sec. ason PROVIDE MFGR.INSTALLATION SPECS.
❑
Owner oats
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
'
I hereby affirm under penalty of perjury one of the following declaration:
I have and will maintain a Certificate of Consent to self-insure for Workers Compensation, Bulldln
as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which this g {p 7
permmmJJJttt Is Iasuetl. 15` �/ r Q N1
have and will maintain Worker's Compensation Insurance,as required by Section 3700 o/ ��� ( 7�/ $815mIC �i
theabor Code,for the performance of the work for which this permit Is issued.My Worker's 142—
/ {7 ,�
Compensation In.0 ce carne entl Policy number are: Q Total (a.--(—
Carrier Policy Nd.•57�'17 lIZ,zS PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need not be completed If the permit Is for one hundred dollars($100)or lase.)
I certify that In the performance of the work for which this permit Is Issued,I shall not employ r (/
any person in any manner so as to become subje tome rkar.campenaan.a Lew.of can• All roofs shall be inspected prior to any roofing material being
fertile. installed. If a roof is installed without first obtaining an
Date_�Applicant I pp inspection,I agree to remove all new materials for inspection,
NOTsubject2 the Workers'Compensation previafter sionis Of thellL$ mCode,Exemption,
mustuforthwlithbecome Comply Applicant understands and will comply with all non point
with such provisions or this permit shall,,be deemed revoked. source regulations.
I certify that 1 have read this application and state that the some Information Is correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentloned property for in. ,s
gip(We) purpose..
(We)agree to ender Indemnify and keep harmless the City of Cupertino against sequence C 7
of the gran,costa and expenses which may In any way accrue against said City In consequence
' of the granting of mle permit SIGNATURE UF;4kPPLICANT IDATE
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