R-5693 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO
NUMBERR- 5693
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 160 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL—ZCOMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
VES ❑ If yos—I understand that a Class A
NAME `I roof assemlNy is required.
�— NO Initial I.C.B.O.N
ADDRESS 1 O 3 V ( S+X N J EXISTING ROOF COVERING
PHONE 11 1 - 7`7 NUMBER OF EXISTING COVERINGS C9
CONT d e1I
0S I D TO BE REMOVED O� TO BE RETAINED
NAME/ // T
ADDRESS S-6 L N rl S� SGN .5 Se Ga, TYPE OF ROOF COVERING
CITY&ZIP c�
—7 EXISTING
PHONE 4 0 >S �q53�- L '� BUILT-UP ROOF
LICENSE
NUMBER - / ASPHALT SHINGLES 10LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em Ilcensed under provisions of Chapter 0(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and /
effect.
WOOD SHINGLES ]l^
License CIe39 Llc.Number y
Dote Contractor OTHER(SPECIFY) ❑ C
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am 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
soplicart.eller,improve,demolish,sign dstaement that
Is licenses Issuance,to so
the BUILT-UP ROOF —I /
applicant for such prove,to file ah,or re air an structure,
that he le for to its
al the provisions 141--I////
of the Contractor's License Law(Chapter g(commencing with Section 7000)of DIA 910n 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 five hundred dollars($500).): WOOD SHAKES El
I,as owner of the property,or my employees with wages as their sole compensation,.111 do
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profen
Maine Code:The Contractor's License Law does not apply to an owner of property who builds or WOODSHINGLES El
thereon,and who does such work himself or through hes own employees,provided that
such Improvements are not intended or offered for sale.11,however,the building or Improvement
is sold within one year Of completion,the owner-builder well 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 conimctor(9)licensed pursuant to the Contractor's License Law. PROVIDE MFGR. INSTALLATION SPECS.
❑1 am exempt under Sec. ,B B P.C.for this reason
Owner Data APPLICAT19N DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: _e�
❑I have and will maintain a Certificate of Consent to sell-insure for Workers Compensatlon, ty/ t® Building I u't
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this I _
permit is issued.an r� �� �^ Seismic❑I have end will the performance
Worker's Compensation the workfor Insurance,e9 required by Section 3700 of
the Labor Cotle,for the performance of the work for which this permit is Issued.My Workers `. Total
'Compensation Insurance carrier and Policy number are � (/�,
carder Policy No. PE Myf AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.
(This section need not be completed If the permit Is for one hundred dollars(31 Or lees.)
I certify that in the performance of the work for which this permit Is Issued,I shall of employ
any parson In any manner so as to beona,cuClac4bTB Workers'Comp sedan All roofs shall be inspected prior to any roofing materi I being
^ installed. If a roof is installed without first obtaining an
Date • • l Applicant � inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: Isubject to the Workers'Compentl
saeon provmakiisionls ofe
the i Labor Code,icate yolu of mustufo thwlllhbecome comply Applicant understands and will comply with all non point
with such provisions or this permit shi deemed revoked. Source regulations.
I cartity that I have read Misapplication antl state that the above Information 19 correct.I agree
to comply with all city and county ordinances and state laws relating to building,construction,endTrings to be class" "or better.
hereby authorize representatives of this city to enter upon the above
-mentions property for Im ��—
spectlon purposes.
13
(We)agree to save,Indemnify and keep harmless the City OI Cupertino against liabilities,
judgments,costs and expenses which may In any way accrue against said City In oneequanca SIGNATURE OF 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