R 5220 (2) APPLICATION FOR CITY OF CUPERTINO NUMBER R- 5220
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 LASTCALLED INSPECTION.
/• BUILDING ADDRESS
98 S 5 �
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
/✓n- YES ❑ If yes—I understand that a Class A
NAME / �(?�Jl-/ roof assembly is required.
cc NO ❑ Initial I.C.B.O.N
ADDRESS- X74/19 LAS EXISTING ROOF COVERING
w
PHONE 7S5 — OSSp NUMBER OF EXISTING COVERINGS
/ CONTRACTO
NAME ' r '
^� TO BE REMOVED + TO BE RETAINED
ADDRESS Vf TYPE OF ROOF COVERING
CITY&ZIP
EXISTING
PHONE ��� T7 Qb 9 ? BUILT-UP ROOF ❑
LICENSE SS"973 6 ASPHALT SHINGLES ❑
NUMBER
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect.
rn. ( WOOD SHINGLES AI
Llcenee Clear ✓� Llc.Number ��� `�
Date 3 Cantnra OTHER(SPECIFY) Ni�lU ��Z77{9
OWNER-BUILDER DECLARATION 1 PROPOSED %WW
I hereby affirm that 1 am exempt from the Contractor's License Lew for the owing reason. /� / t
(Sec.70315,Business and Professions Code: Any city or county which requires a permit to CITY 1 OF VUf,EHI(NO
construct,alter,Improve,damollah,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF El
for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Lew(Chapter g(commencingg with Section 7000)of Division 3 of the
• Business entl Pro16961onr Cotle)or that he Is exempt I arefrom 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 Dull.anelry of net more than five y employees
yellers(h wage:
❑Irks and wner
sthe ructure
Is
I tended oyeeered wapeeas(Sec,their sole compensation,sandPrllido WOOD SHAKES ❑ T/y'JWT,yI—Qy/\.J.
the work,entl the structure le not Intended or offered for eels n owner
of property
and ullds o-
eloneCotle:The,anwho d License Lawdoes not apply toenowner ofproperty whobuetleor WOOD SHINGLES
Improves thereon,entl who does such workhimselffor or through his own employees,provided that ❑
such Improvements are not Intended the
offered for leer,If,however,the en of pr oiImprovementIs
not ld bull thinor
prove for purpose
sthe owner-builder will have the burden of proving that he dad OTHER (SPECIFY) ❑ /- l..
not build or Improve for purpose of sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to construc41
t
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO. 37 G
0
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with k contractor(e)licensed pursuant to the Contractors License Law. PROVIDE MFG R. INSTALLATION SPECS.
❑1 am exempt under Sec. ,B$P.C.for this reason
Owner oma
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, L-� Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this g
per Reissued �[
�� °�3 9�a �3, T�$ Seismic /'`�
have entl will maintain Worker's Compensation Insurance,as required by Section 3700 of D
th La or Code,for the performance of the work for which this permit Is Issued.My Worker's �rj(',
Compensation In—s conn centernd PPo11 number ere: �y �• Total 40—,—P g
s Carrier' �!'`^' PolicyNor"u-�6 13Z7i PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed If me permit Is/or one hundred dollars($700)or IeeeJ
` I certify that In the performance of the work for which this permit la Issued 1 shall not employ
any person In any manner act as to become subject to the Workers'Compeneetlon Laws of Cell- All roofs Sh a inspected prior to any roofing material being
rarnia. installed. it a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
ctEeOCr lsthis
Certificate
yultlbecome
subjetothWorrkereC mpeneetlprovisions of the Labor you Exemption,you
comply Applicant understands and will comply with all non point
with such provisions or this permit shell be deemed revoked. Source regulations.
1 certify that I have read this application and state that the above Information Is correct.I agree
h complyyauthorize
rep and county of this cls andstateupon the
above-bulb n ed property f,antl All ZoofVerin t „OT I)etter.
hereby authorize city and co my of this city to enter upon the sing to building
enllon c property br ned /
sp(W )agreeaee. /4�a.3� x�
(We)spree to save,Indemnity and keep harmless the City of Cupertino agklnrt liabilities,
judgments,coats and expanses which may In any way accrue against said City In consequence
• of the granting at this permit, SIGNATOR” FAPPLICANT DATEz
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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPV