R-5203 (2) PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 520
3
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 LAST CALLED INSPECTION.
BUILDING ADDRESS
OQ. �`� `V ( RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES It yes—I understand that a Class A
NAME r e 0 V) roof assembly Is required.
`-� NO ]� Initial I.C.B.O.#
ADDRESS V Q C,,Ct EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS
PHONE
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP EXISTING
PHONE BUILT-UP ROOF ❑
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
hereby affirm that I am licensed under provisions of Chapter 8(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 ❑
License Class Llc.Number
OTHER(SPECK) ❑
Date Contractor /
OWNER-BUILDER DECLARATION PROPOSED
hereby affirm that am exempt from the Contractors License Lew for the following reason. ���
(Sec.7031.5,Business and demolish,
or rep Code: Any city or county which re,also a permit to
constructapplicant
er.such
improve,to file signed staairtement
anystructure,Is livenor to He!pursuant also requires the BUILT-UP ROOF ❑
applicant for such permit a Ills Ii signed statement that g Is licensed pursuant to the provisions
of the Contractor's License Lew)or that S(commencing with om and 7000)of for the 3 le the /
•
exemption.
and violation
Code)or the.he Is exempt therefrom and the beets for the alleged ASPHALT SHINGLES
ao it pen.Any violation of than
five 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of not more then five hundred yenara(h wag 1: WOOD SHAKES
❑I,as owner of the tuneproperty,not
to employees with wages(S c.7 sole compensation,will do ❑
the work,and the structure Is not intended ores not for cele(Sea owner
of Business and builds
o-
Ilona Code:The Contractor's License Lew does not apply to an owner of property who provided
t or WOOD SHINGLESImpr ❑
such Improvements
thereon,n,and who does such work himsereefed or .if,how hie own employees,provided Iha.
such Improvements are not Intended tor he own tl for Bale.if,however,the en of pr or Improvement
n sold tbuildwithinor
prove for purpose
sthe 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 contractor$to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Lew 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 Contmctor(s)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
1 am exempt under c. ,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: P A _1
❑I have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, r Building ��/�(/�
as provided for by Section 3700 of she Labor Code,for the performance of the work for which this o
permit leve and - 71996 Seismic �•"0
I have and will the performance
Worker's Compensation the work
Insurance,as required by d.My
Worker
of
me Labor Code,for the performance of the work for which this permit is issued.My Worker' IT �0�,..1 Total
Compensation Insurance carrier and Policy number are: llxz 11 Y )f-� W
Carrier Policy No. PERRY AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C100)o (�T/J /al
(Tela fysectionttI need not be ante of the
If the permit Is for one hundred sued,dollarsI($100)or lasso \`IL//�j�• V
I verso That In the performance of the work for which this rkers'is issued, shell net employ
/ 17
C iorniaer$on in any manner so as to become aublept to the worker;compenlauon Lowe of can- All roof.^shall be inspected prior to any roofi g material being
installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
subNOTICE ject to the wok�eCOompeosetlo provisions oeheil born Coda you must fothwlthbComply Applicant understands and will comply with all non point
with such provisions or this permit shaill deemed revoked. source regulations.
Iceplly thet have read thisapplicationantl erstethattheabove Information tbuilding lecorrect,!agree Wol��
to comply with all city and this aounty ortlation and
state
to that the
relating bantling 18 Correct.I agree
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. �y
(We)agree to save,Indemnify and keep harmless the City of Cupertino against Ilabilitles,
judgments,casts and expenses which may In any way accrue against said Clty In conaequenro IGNATURE OF APPLICANT DATE
of the grantingof 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