R-5252 (2) PERMIT R_ 5252
APPLICATION FOR CITY of CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777.3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 190 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
l J l aq �1an� 9�U2/ill¢_ RESIDENTIAL k�_COMIMERCIAL OTHER
OWNER'S (^//► �/�,,.s,. /x HAZARDOUS FIRE AREA
oi [.air / ;a' a) �c.0—i6_ VES ❑ Ifyes s Imblyunderstand is required. ClassA
NAME roof assembly is required.
NO ❑ Initial I.C.B.O.#
ADDRESS 'l a � EXISTING ROOF COVE NG
PHONE NUMBER OF EXISTING COVERINGS
CONTRA 'S
Vp�,/K�/y,/�•)l (l/-C/J, TO BE REMOVED TO BE RETAINED
NAME
ADDRESS // /' j-1q TYPE OF ROOF COVERIN
ZIP a P [// --'TQ l /'[tr/CX EXISTING /
PHONE L.o-/ — / 7 7 L/ BUILT-UP ROOF ❑ S S G.�
LICENSE ❑ //
.NUMBER ASPHALT SHINGLES ^
LICENSED CONTRACTORS DECLARATION ll#
I hereby affirm that I em licensee under provisions of Chapter 9(commencing with Section WOOD SHAKES
]000)of;Division 3 of the Business and Professions Cada,and my license is in full force and
effect.
9 C�
WOOD SHINGLES ❑
License ss � Lic.Number
Date Contractor OTHER(SPECIFY) ❑ __
OWNER-BUILDER DECLARATION PROPOSED Ap
I hereby affirm that I em exempt from the Contractors License Lew for the following reason.
(Sac.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,eller,improve,demolish.or repair any structure,prior to Its Issuance,also requires the BUILT-UP R0O ft O n ❑
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions 5 8' �C�}
of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Y
• Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT WrINI `G- SES ❑
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to �l L I/,
a civil penalty of not more than five hundred dollars($500).): WOOD SHAKES `Ur`�I'I'i
E]1,as owner of the property,or my,employees with wages as their sole compensation,will do E3
the work,and the structure Is not intended or offered for sale(Sac.7044,Business and Profes.
sions Code:The Contractor's License Law does not apply to an owner of property who builds or' WOOD SHINGLES El
thereon,and who does such work himself or through his own employees,provided that
such Improvements are not Intended or offeree for sale.If,however,the building or improvement
is sold within one year of completion,the owner-builder wi 11 have the burden of provi ng that he did OTHER(SPECIFY)
not build or Improve for purpose of sale.).
❑L as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sac.7044,Business and Profassions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.zlllii�.g`'
Il
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Are APPLICATION DATE VALUATION PER
FEE
WORKER'S COMPENSATION DECLARATION
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, �/ Buildin
es Prov by Section 3700 of the Labor Code,for the performance of the work for which this h
per sissu tl. f^�,,,/� /�/� lO�� $BISrr11C
have and will maintain Worker's Compensation Insurance,as required by Section 3700 of / / �I /
thI
ebor Cotle,for the performance cl the work for which this permit is issue/d,,xMy Worker's
/� (((
Comperu5p(lonlnsr urapcocerrla Policy nu br are: /�//V7W7-9L!/ Total
Carried\/,/J_(•,s }�- Policy N?/IL/ PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NCQ !.
(This section need not be completed if the permit is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this permit Is Issued,I shell not employ
any person any manner so as to become sub ect to the Workers'Co pensation Laws of Cali./ All roofs shall be inspected prior to any rooting ate al being
lornla. n'' installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
to ' It,
making
Certificate Exemption,
sKould become
subjecto the WorkersCompansetprovisions of theLeba cooyou mstforthwiithcomply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked, source regulations. -
' I certify that l 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 building construction,and roof coverings to be class"C"Of better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in. I11
� I
hereby
purposes. IF 12
-//
(We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may In any way accrue against said City in consequence IGNATUR O 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