R-5814 PERMIT
APPLICATION FOR CITY of CUPERTINO NUMBER R" 5 814
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 160 DAYS OF PERMIT ISSUANCE OR
160 DAYS FROM UST CALLED INSPECTION.
BUILDING A�D/}D�RESS�./•!� �J ///�//"T�)L
14j `��"f ✓/ RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
NAME ,Q YES ❑ If yes—I understand that a Class A
root assembly Is required.
NO Initial I.C.B.O.ROD
:f
ADDRESS Z EXISTING
PHONE cz>) NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS �/�-�jN � _ COVERING
CITY 8 ZIP
(� EXISTING
PHONE 7U6�V/�6��7 BUILT-UP ROOF AE
-
LICENSE .� ASPHALT SHINGLES
NUMBER
SE
LICEND RACTORS DECLARATION yy"
hereby affirm that I emusi nes under fearla of Chapter a(commencing calif Section WOOD SHAKES
701X7)of DNlslon 3 of the Buelnaee and Profesebns Cotla,and my I se le In full lone and /
effel - 73 , WOOD SHINGLES ❑ C tl-+/
License Cis" Up.Number
OTHER(SPECIFY) ❑
rda
Date Contractor q
OJJNER-BUILOER DECLARATION PROPOSED Jry�s•
1 hil affirm that I em exempt from the Contractors License Lew for the following reason. �
(Sec.7031.5,St aineas and Professions Code: Any city or county which requires a permit to rv,.� /{ ,
cnnsect,eller,Improve,demolish,or repelr any structure,prior to Its lasuence,also requires the BUILT-UP RP�Or
applicant for sucn permit to file a signed statement that he Is licensed pursuant to the pgvislons OF
of the "and Pre License Lew(Chaplet a Is exit ndrg with Section 7000)of DMsbn 3 of the
�Urrryyyf
Bualneae end Alustllorre Code)or 0311 3e la exempt anfortherefrom and the beds far dire applicant
to ASPHALT SHINGLES x
a chat pen.Artyf not m n of Section 7031.5 by arty applicant for a permit eub)ecM the epulkent e
e civil penalty of not more sen Hoe hundred
employees
dieners ❑ `��
thew rk,end the stv urs is W intended o offeTedi to wages as their
7044,,eWe cusineav and Prroi� WAD SHAKES
slows Cade:The Contractors License law dices not appy to an owner of property who billets or WOOD SHINGLES
Improvae thereon,and wnd ckm such work IJmsed or through his own empkyees,providad that ❑
such ffin emene are not intended or offered for eels.If,howl Me building a mproyemmt
is sdtl wiWn me year of completion,the owner-bilker will hlye the burden of proving that he Ori OTHER(SPECIFY) ❑
not build or Improve for purpose of"o.).
❑I,as owner of the property,em exduehroy contracting win licensed comractons to construct
the prefect(Sac.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO.
appy to an owner of property who bilks or lmpravee thereon,and who corsets for such pvJec s
with a contrador(e)licensed pursuant to the Compactces License taw. PROVIDE MFGR.INSTALLATION SPECS.
❑1 an exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION FEE-
WORKER'S COMPENSATION DECLARATION
I hereby affirm under pendty of perjury one of the following declaration:
1 have and will maintain a Certificate of Consent to seff-Insure for Workers CoarNmurtlm, u dlnq
as provl a for by Section 3700 of the Labor Code,for the performance of the work for which this _
permit Is Issued. (J'� a $elSffllC
❑I have and will m In orkers Compensation Insurance,as required by Section 3700 of Dv' if
the Labor Code, pe mance work for which this permit is issued.My Workers (/
Ccmpenaatbnl eu br oil mbar am: O Total
47�7
Caner Pollcy NaPERMIT AUTHORIZATION. TE
CERTIFICATE OF FX( MPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.
(The section need not ba completed If the permit Is for one hundred collas($100)or lase.)
I tartly that In the performacm of the work for which this permit Is Issued,I shell not employ
any person In any manner so as to become aupm to the Workers'Compensation Laws of Cell- All roots shall be I petted prior to any roofing material being
forma. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
suaaol to
NOTICE
wAPPLICANT:
lPerec mp¢naeu nm'koiwne �Q aii%t�L�w oa�mptlor��tubehwbhbecome Ap nt understands and will comply with all non point
with such proyalons ow this permit snail be deemed revoked. Ym comply Urce eg Ulatl On S.
I cortiy that I have read MIs application and elate that the ebove Informellon le cortect. agree
to comply with all city and county ordinances acl state levee relating to bulking construction,entl ' All r00 OV In to be CI85S"C"Of ballet.
hereby authorize repreaentallves of this city to enter upon the ebwe-mentlmatl property for In.
specam pumoaes.
(We)agree to save,Indemnity and keep harnaes i the City of Cupertino against liabilities,
judgments,costs and expenses whkh may In any way accrue against sald Gty In consequence
of the granting of this permit. $IGNA F APPLICANT DATE
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