R-5592 PERMIT
APPLICATION FOR CITY of CUPERTINO NUMBER R 5592
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IFNtlRKISNOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
a0
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ H yes—I understand III a Class A
NAME roof assembly is required'
NO Init I.C.B.O.
ADOREss EXISTING ROOF COVERING
PHONE -' - NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
TO BE REMOVED / TO BE RETAINED
NAME
ADDRESS - TYPE OF ROOF COVERING
CITY 8 ZIP
EXISTING ,
PHONE BUILT-UP ROOF ❑
NUMBER ASPHALT SHINGLES - ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am Ikerreeo under provisions of Chapter g(commencing It�S"affllyyyn WOOD SHAKES
7000)of Divalon 3 of Me Buelnesa and Proremdne Code,and my license Is In I�ce,f`ad/
effect. T WOOD SHINGLES
Ucenm Clan Lk.Number El
Date Contractor OTHER (SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from the Comanctars License Law for the following reason.
(Sec.7031.5,Business,and Professions Code: Any city or county wil requires a permit to
construct,after,Improve,tlemolleh,or repair any structure,prior to he Issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is licensed Wtauant to the provisions 1
of the Contractors License Lax(Chapter 0(corrrmpndrg with Section 7000)of DNisbn 3 of Me rr nn QQ
• Business and Professlone Code)or that he Is exempt therefrom and Me basis for the staged ASPHALTpSHIN LEbD *CZA 30y()
exemption.Any violation o1 Section 7031.5 by any applicant for a permit elthe applicant to �/// a�
a cMl penalty of not more then five hundred dollars(5500).): O/
❑I,as,owner of the propend,or my employees Mth wages as their sole compensation,will do WQ9A,SHAkJ030 ❑
the work,and the structure Is mi Intended or offered for sale(Sec.7044,Business and Profes- r/}(/(J1 9q
sons Code:The Contractors Lcens,Law does ml appy to an owner of property who builds or WOOD SHI LES (/ ❑
Improves thereon,and who does such work himself or through his own empkryees,provided that
men Improvements are ml Fntended or offered for sale.If,however,Me Wilding or Improvement on4 /4'y
Is sold witNn e year of completion,the ownerWikfor wig have Me burden of proving that he did OTHER SPECI h
not b IId a Improve for purpose of sale.). ( ❑
I,as,owner of the property,em exclusively contracting with licensed contrecrom to construct
protect(Sec.7044,Business and Proresslarne Code:The Contractors Ucense Lew does not PROVIDE I.C.B.O. REPORT NO.
appy to an owner of property who builds or Imprwee thereon,and who contracts for such projects
with a contractions)Iltammul Pursuant to the Convectors License Law. PROVIDE MFGR. INSTALLATION SPECS.
❑I em axe radar Sec. ,B&P.C.for MIs mevm
owner - Dere
WORKER'S COMPERATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of Me following decdmtlon: '� y
❑I he"and will maintain a Goad icam of Consent ro mti4.re for Workers Corawnseum. Building —\
be provkfeo lar by Section 3700 of Me Letter Code,for Ore performance of the work for which this )
permit Is Issued. Y/,U 10 V U (/ Seismic
C]I have and will maintain Workers Compenmtdn Insurance,as,required by Section 3700 of i ( O
Me labor Code,for the performal of the work for which this permit Is Issued,My Workers
Componmtlon Insurance camier and I number are: Total
Carder PolkryNo. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C�
(mu section need cot be completed it the permit Is for one hundred dollars(5100)a tem.) -
certify Mer In the periormence of the work IOr which this permit re argued,
shell cot employ
arty person In any manner as as to become subject to the Workers'Compensation Laws of Cali- All roots Shal Ins acted prior to any roofing materia Ing
Islas. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
jToBorrCmeetlnp soti o Imo usuahowldbecomrysubectWorkks'Compensation loe of me LboyomtfthApplicant understands and will comply with all nonpoint
with such provlslons or this permit shell be deemed revoked. source regulations.
I car ity that I have read thio appficatlon and state that the above Information Is correct.I egret
to comply with all city and county ordinances and Mile leve roll to building construction,and All ro7corinbe�cllbetter.
hereby authorize represintatives of this ciy to enter upon Me abo e-menibned property for In-
speceon purposes. is
(We)agree to save,Indemnity entl keep harmless the City of Cupertim against Ilebllibeau z�
judgments,costs and expenses which may In anyway accrue egalnet ssd City In conmquence SIGNATURE APPLICANT jI DA
TE
of the granting of MIs 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY