R-5668 PERMIT
APPLICATION FOR CITY OF CUPERTINO - NUMBER R" 5668
INSPECTION DIVISIONPERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORT(IS NOT STAFRED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
-t ' RESIDENTIAL COMMERCIAL / OTHER
—
OWNERS
.1 HAZARDOUS FIRE AREA
NAME `J U P/t- L "%.o - ! C -r-2 YES ❑ r yes octf s I assembly
is req iret a Guess A .
NO ❑ InNal I.C.B.O.r•
ADDRESS /(/ EXISTING ROOF COVERING
PHONE 7 7 s D NUMBER OF EXISTING COVERINGS I
CONTRACTOR'S
TO BE REMOVED l TO BE RETAINED
NAME
ADDRESS y TYPE OF ROOF COVERING
ZIP .
CITY aP / EXISTING
`
PHONE T OR " 34n CI /�� BUILT-UP ROOF
LICENSE E]NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter S donvnoncog wfth secron WOOD SHAKES ❑
7000)of DMslon 3 of Me Business and Proletiol Cade,and my kenee is In lull force end
affect.
WOOD SHINGLES ❑
ulcerate Class Lid.Number
Date
� 2A r-C`J CoNramo OTHER (SPECIFY)
OWNER-BUILDER ode: y ION POSED D \
I hereby affirm that I em exempt from the Contmclors nes Law for the blbwing reason. "
(Sec.7031.6,Business end Professions Code: Any city or county which requlree a permit to '
construct,after,Improve,demolish,or repair any structure,prior to he Issuance,also requires the - BUILT UP ROOF
applicant for such permit to file a signed statement Met he is ilmneed pursuant to Ihe provlelone
of the Contractors Lker,se Lew(Chapter B(commandwith Sector,7000)of DMaon 3 of the
Business and Professions Cade)or that he Is exempt ht erelrom and the basis for Me alleged SPHALT SHINGLE 3 ❑
•. exemption.Any vlolatlon of Secuon 7031.5 by any applicant for a permit subjects the applicant to
a cE) ,analty s owe not more than Ilya hundred dollars wind
wag.): AKES --�
❑I,as owner of Me property,or ray Intended
or o e wither sale ae their sole compessa nd will s. ❑
Me work,and the alld dos not Insended or offered for eels(Sec.7044,property
end Proosr Oxo
alone Code:The Cold does License Lew,dose ret apply to an owner of property who bullda or WOO IN O J
Improves thereon,aro who does such work hlmseft or through hie own empoyeee,provided that ❑
such Improvements are rel Intended or offered for see.If,howaaer,the building or Improvement '
Is sold within one year of completion,Me ownerbuloer will have the burden of proving Met he did OTHER(SP IFY) ❑
not build or Improve for purpose of eels.).
❑I,as owner of Hie property,am exchraely,conttacdng with licensed correctors to construct
the project(Sec.7044,Business aro Professions Cade:The Contractor's uterus law does not PROVIDE I.C.B.O.REPORT NO,
apply to an owrer of property who builds or Improves thereon,and who contrecte or such projects
with a contreaogs)licensed pursuant to the Contractors ucanse Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.or file reason
Owner bete APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of Ma ollowing dedaratlon: /
O 1 have and will mandrel a Certificate of Consent to"If-Insure or Workers Compensation, Building
an provlded for by Seton 3700 of the Labor Code,for Me performance of Me work for wNch Mb D D Q
permit is issued. Seismic ( (K
❑1 have and will maintain Workers Compensadon Insurance,as required by Section 3700 of
Me Lobar Cade,for Me performance of Me work for which tills permit is Issued.My Workers /V-1r-0 Q U 7•y
Compeirmhon Inaurence��er entl icy number eta: Total �� —
Carder 11 M.s�n�./ �1i/'.(I • � - Pal4y No.ill �U � PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPT10N FROM WORKERS'
COMPENSATION INSURANCE N.CQ o
(This section need not be completed If the permit 4 for ore hundred dollars($100)or lees.)- Z
I mmty Met In the performance of the work for which this permit Is Issued,I shell not employ
any parson In any manner so as to become subject to the workers'Compensa0 awe of I- All roots shall be inspected prior to any roofing material being
formic. installed. If a roof is installed without first obtaining an
Date ^2 Ayplicent I ' inspection,I agree to remove all new materials for inspection.
Subject to the E TOWorkeraC mpensaikm provisiothrm Tina LLaatbor Cao.oro mus forrtihhahh w ma Applicant understands and will comply with all non point
with such provisions or MIs permit shall be deemed revoked. - - Source regulations.,
I corny that I have read this application entl state that Me soave Information Is correct I agree
to comply,with all city and county ordinances and state kora raising to Wilding conetruUlon,eM 11 roof GOVe S t0 be class" Of better.
harsh)authorize reprommothdre of this city to enter upon the abate-mantonad y for In.
specton purposes. 2'? /
we)'agree to save,Indemnify end keep harmless the City of Cupertino ap.Inst IIelIltles,
jutlpmenW.core end expenses which may In arty way accrue against sold Gty In wneequertce I APPLICANT . DATE
�� • al tFe rentln of tole 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