R-5382 (2) PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 5382
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
' WITHIN 180 DAYS OF PERMIT ISSUANCE OR
BUILDING ADDRESS
180 DAYS FROM LAST CALLED INSPECTION.
SO 7 hY',l1�\J
a'`-//Ie ' RESIDENTIAL X COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES 0 If yes-I understand that a Class A
NAME c1 f assembly is required.
V NO Initial LC.B.O.N
ADDRESS - , L/ EXISTING ROOF COVERING
PHONE d' — ��/ NUM ER OF EXISTING COVERINGS I
CONTRACTO -
TO BE REMOVED / TO BE RETAINED
NAME
ADDRESS /� C p TYPE OF ROOF COVERING
CITY&ZIP
/�-a9`z 11� tet - - J . (.51 X>EXISTING
PHONE \`f� j�C�i _U 6 BUILT-UP ROOFLICENSE
❑
NUMBER S e�! 7 3 - ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with SOCtlim WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license la in full force and
D
c,
effect. WOOD SHINGLES � � ❑
Cleanse Class � � Lia Number
ER (SPECIfOC�' ,14 pEC.CJ
Date Contractor n p ]�
OWNER-BUILDER DECLARf� ION (/ D /tIT,
hereby affirm that am exempt from the Contractors License Lew for the following reason. / VII (Jf-
(Sac.7031.5,Business and Professions Code: Any city or county which requires a permit to Iq - �'urtN�)N(Q
construct,site,improve,demolish,or repair any structure,prior to Its Issuance,also requires the 76d 11_TUP ROOF
applicant for such permit to fife a signed statement that he Is licensed pursuant to the provisions
' of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 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(5500).):
❑ WOOD SHAKESI,as owner of the property,or my employees with wages as their sole compensation,will do ❑ r
the work,and the structure is not intended or offered for sale(Sec.7044,Business and Profes-
sionsCode:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑ -.� n
improves thereon,and who does such work himself or through his own employees,Improvement that a$
such improvements are not intended such
or offered ler sale.If,ugh hishowever,the building or Improvement
Is a III within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) `�, f�
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 Contractors 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 contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PE T FE
WORKER'S 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, O� I I g
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this //'//'I/?-7 i
P
rm't is issued. V -7 I -7 L/O $ IC
have and will maintain Worker's Compensation Insurance,as required by Section 3700 of / f
ih Labor Code,for the performance of the work for which this permit is issued.My Workers Total
Compensa�tio IIJ�`�surya/Jnca car�riJer and Poliycy number are:
Carrier��+r.�r-^- 'T f'I-"—K - Policy No.I�'s Jr ��Z PERMIT AUTHORIZATION D
CERTIFICATE OF EXEMPTION FROM WORKERS' s .
COMPENSATION INSURANCE N.C.[]
(This section need not be completed If the permit is for one hundred dollars Sl 00)or less.)
I certify that in the performance of the work for which this permit is issued shall not employ
any person In any manner so as to become subject o the Workers'Con enealion Laws of can- All roofs shall bei pe ed prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date 1Q li Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TD APPLICAN : II,after making this Ce if ate of Exemption,you should become Applicant understands and will I with all non point
subject to the Workers'Compensation provisions of I Labor Code,you must forthwith comply pP comply y p
with such provisions or this permit shall be deemed revoked, source regulations.
I certify that I 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 Allro;f coverings tobQ/�laS�'s,CC"�orr.,better..
hereby authorize representatives of this city to enter upon the above-mentioned property for In- i% /�///L.f...� j
In-
spection purposes. r
(We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,
V
ludgmeots,costs and expenses which may In any way accrue against said City In consequence SIG TU OFA PLICAN 6 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