R 5205 (2) PERMIT R_ 5205
90R
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IFWORK ISNOT
WITHIN 180 DAYS OF PERMIT ISS1B0 DAYS FROM LAST CALLED INS
BUILDING ADDRESS
(0,J St RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
NAME G YES ❑ It yes-I understand that a Class A
T roof assembly is required.
NO X Init al I.C.B.O.#
ADDRESS I�7'D S'_ /ET��11yC ALP- EXISTING ROOF COVERING
PHONE Y�< 9.9"41,- yC 0 Y NUMBER OF EXISTING COVERINGS
A
CONTV OR'S
NAME C^4. el-r C n 110 A. Z-f C C Z TO BE REMOVED L _ TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
CITYaZIP N., '16—re Z
EXISTING
PHONE ! y'sf 7' �C^ LO 7 BUILT-UP ROOF
LICENSE NUMBER` ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)al Division 3 of the Business and Professions Code,and my license is In full force and
effect.
License Class 'M S 9 ?�P�T y WOOD SHINGLES ❑
Lic.Number
Date 9�27�9 C Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt Iron 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 9(commencing with Section 7000)of Division 3 of 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 live hundred dollars($500).):
❑I,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 Intentletl or offered for sate(Sec.7044,Business and Profes-
alone Code;The Contractor's License Lew does not apply to an owner of property who bullas or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,provided that ❑
such Improvements are not Intended or offered for sale.If,however,the building or Improvement
Is sold within one year of completion,the ownerrbullder 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 PROVIDE LC.B.O.REPORT NO.
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not
apply to an owner of property who builds or improves thereon,and who contracts for such projects
with a contractor(,)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
[II am exempt under Sec. ,B 8 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to sell-insure for Workers Compensation, Building c t y�I
as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which this ,l♦°
permit Is Issued c 19(�96
Seismic
[31 have and will maintain Worker's Compensation Insurance,as required by Section 3700 o1 1x7 A
-the Labor Code,for the performance of the work for which this permit is Issued.My Worker's TPI sI
Compensation Insurance carrier and Policy number are: - 1l1- (;Ut-L y r r !1 4ryZ y Total
Orler -=T t 7_ Xy-02- P POIIcy N. Ff`>'� /J3 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need net be completed II the permit Is for one hundred defiers($100)100)of less.)
J I certify that In the performance of the work for which this permit is Issued,l,hall not employ '
any person In any manner so as to become subject to the Workers'Compensation Laws of Calf All roofs shall be inspected prior to any roofing material being
Ionia' installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE subject to theOWoPerrs'Compensatlan proviafter sions of theicate of Labor Code you must lodhwlitlbecome
h Comply Applicant understands and will comply with all non point
with such provisions or this permit shalCbe 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 bulltling Construction,and All roof coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes. '
(We)agree to ands,Indemnity end keep harmless wa the City of Cupertino Ci egalnst liabilities, Z I
• -of the grating
conte and permit. s which may In any way accrue against said City In consequence i
of the greening Of this permit SIGNATURE OF APPLICANT-,' DAT
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