R-5514 (2) MIT
APPLICATION FOR CITY OF CUPERTINO
Pia BER R- 5 514
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
'
WITHIN DAYS PERMIT ISSUANCE OR
WI DANSS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS \^\,'}1p S I L-.!I mRESIDENTIAL COMMERCIAL OTHER
OWNER'S �,// ` / HAZARDOUS FIRE AREA
�� �L YES ❑ If yes—I understand that a Class A
/�/
NAME �/Vl t
roof assembly Is required.
NO Initial I.C.B.O.k
ADDRESS_- iii as Q L U e N
EXISTING ROOF COVERING
PHONE — 81 NUMBER OF EXISTING COVERINGS 2—
CONTRACTOR'S CONTRACTOR'S
NAME (� R a,+( S 00�I n TO BE REMOVED TO BE RETAINED
CADDRESS ITY 8 ZIP I •6 • �./a'x I'72(. O S TYPE OF ROOF COVERING
'/ Q S03 EXISTING
PHONE)10 0 35S/`I Z�:j,3 BUILT-UP ROOF ❑
NUMBER ' 49 � ASPHALT SHINGLES
ICENSE LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 am Ilcensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ❑
ode
39
]000)of Division 3 of the Business and Professions
Ctl my license Is In 1 II farce and
effect. WOOD SHINGLES
License Class 1�_3 Lic.Number �� ❑
Date Contractor
OTHER(SPECIFY) Q� or
OWNER-BUILDER DECLARATION PROPOSED
hereby affirm that am exempt from the Contractors License Law for the following reason.
(Sec.70315,alter,imp ove entl Professions Cotle: Any city or county which requires e permit e 7
applicnstrunLoruch permit t edea signed stath,or repair eny ment that
prior tolls issuance,also reproves the BUILT-UP ROOF ❑
applicant for each permit to Ills a signed statement that ha Is licensedSection
pursuant to the provisions
' of the ss an Pro License Law(Chapter 9(commencingisexptwith Section]000)of for the 3 of theBusine /
exemption,
and Professions of Code)or that he Is exempt infer a and the basis for me applicant
to ASPHALT SHINGLES
exemppen.Any violation of Section 7031.5 by any applicant for a Permit subjects the applicant to
e civil penalty of not more than flue hundred dollars 1$$00).):
C]1,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-
sions Code:The Contractor's License Law does not apply to an owner of property who builds 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 Ono 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 bulltls or Improves thereon,and who contracts for such projects
with a contrector(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B$P.C.for this reason
Owner Dale AppLICAljtO(SA�,4 VALUATION PERMI
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the fallowing declaration:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, ��� q qp B i
as
pr vitlatl for bySectlon 3700 of me Labor Code,for the performance of the work for which this a4 IU
p rm Is issued. eISn11C
I have and will maintain Worker's Compensation Insurance,as required by Section 3]00 of
the ost otle,))))))or theaJJJyyyorformance of the work for which this permit is issued.My Worker's C11y i CUPEH t4 D0
Cc pan 1' n l uran�arrle�tl Policy number are: I / I'/��J� / Total
Carrier Policy No. - A PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need not be completed II the permit is for one hundred dollars($100)or less.)
1 certify that in the performance of the work for which this permit Is issued,I shall not employ
any person in any manner so as to become subject to the Workers'Compensation Laws of Cali. All roots Shall be irrspected prior to a roofing materiallibeing
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
subject loth Workers'CompTO APPLICANT: ensation rrovtsio>nis f thelLLaatborr CExemption,
de you must forthwith Applicant understands and will comply with all non point
P P Y Pry
with such provisions or This permit shall n deemed that the SOUTCe regulations.
I certify that have read this applicationand state thatws above Information Incorrect. agree
to hereby authorize representatives
rcityep and se county ordinances andstateupon
relating above-mentioned
n construction,f and All roof coverings to be class°C°Or better.
hereby authorize repreeentallvea of this Illy to soler upon the above-mentionetl property for in.
apection(We) purposes. ,7
(We)agree to ands,expenses
and keep harmless the City a against
Cupertino,...cot liabilities, �f _9
judgments,costs and expenses which may In any way accrue against sold City In consequence
of the granting of this Parma. SIGNATURE OF AP CAN��DATE
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