R-5326 (2) PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 5326
INSPECTION DIVISION PERMIT EXPIRATION .
REROOF PERMIT (408)777-3228 PERMIT EXPIPIES IFWORK ISNOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
' 180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
1� QQ S
Q sJ � 4 /1 � 2 RESIDENTIAL !/ COMMERCIAL - OTHER
OWNERSI- + HAZARDOUS FIRE AREA
2 ✓l & YES ❑ If yes—I understand that a Class A
NAME roof assembly is required.
NO ❑ Initial I.C.B.O.W
ADDRESS `1 Q'�l--7GJ EXISTING ROOF COVERING
PHONE• -2 —/ Q NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S
. ` l —p-��'
^/ _ 70 BE REMOVEDy TO BE RETAINED
NAME [a )F- lGC) ccC/t'� ��-� rypEOFROOFCOVERING
ADDRESS
CITY a zlr �3 N I Ty� gS EXISTING
PHONE 18 K_` 0 q2-0 BUILT-UP ROOF ❑
LICENSE /�
NUMBER "[ D ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
hereby eiilrm that I em licensed under provisions Of Chapter B(commencing w ction WOOD SHAKES 117000)of Division 3 of the Business and Professions Code,and my license Is In fIli d
effect.
C I qq/ G WOOD SHINGLES El
License Class INumber `
Date y'Ji 7-7 Conti aor J THEIR(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em 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 Is licensed pursuant to the provisions
• of the Contractor's License Law(Chapter B(commencing with Section 7000)of Division 3 of the P A I
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 live hundred dollars($500).):
❑ ���
I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES 18'0
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes-
slons Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES II��I
improves thereon,and who does such work himself or through his own employees,provided that RLIIy Vr vvrci INV
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 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 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 Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: _a
I have and will maintain a Certificate of Consent to sell-insure for Workers Compensation, O Building n 0
as provided for by Section 37W of the Labor Code,for the performance of the work for which this
permit Is Issued. -yl/ Seismic ri
I have and will maithe pert Workers f the work
for which this as required by Section 370001 __ _
the Labor Code,for the performance Ot the work for which this permit Is Issued.My Workers __`F_//)S�L(�j
Compensation Insurance cerrler and [icy numb rare: 7 Total
Carrier ST ATE Policy No.l3` 300 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE N.C.I]
(This section need not be completed If the permit Is for one hundred dollars S If or lees.) yam/
I certify that In the performance of the work for which this permit Is Issued,I shell not employ
any person In any manner so as to become subis t to t orae a'Compensation Laws of can. All roofs she be Inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date i qAPPllcant inspection,I agree to remove all new materials for inspection.
NAICsubject toEthe WorkereCC mpefnsatlon pro,after ivlalonis C sa4t1tt
abor Codemyyou mustufo forthwith comply become APPllcant understands and will comply with all non point
with such provisions or this permit shall be deemoked. Source regulations. -
I certify that I have read this application and stt the above Information Is correct.)agree
to comply with all city and county ordinancef owa relating tobuilding construction,and Al roof vert sto be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
epeWe)agrpoeea. 7_ /Ol (j
(We)agree s save,Indemnify and keep harmless the City al Cupertino against liabilities, { `
edgmgran coats end expenses which may In any way accrue against said City Inconsequence NATU APPLICANT DATE
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 r