R-5832 APPLICATION FOR CITY OF CUPERTINO
NUMBER PERMIT
R- 5832
INSPECTION DIVISION PERMREXPIRATI N
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
I (51 l/ lxaRESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
1 _ 4Z YES ❑ If lyes s I rrd*is
that. Class A
NAME �I'T4z (q C-f'O roof assemdy is required.
` NO Initial LC.B.O.O
Ria( $/tFCs YI4 + ��� ` f( j.C{ EXISTING ROOF COVERING
ADD
PHONE O NUMBER OF EXISTING COVERINGS
CONTRACTOR'S II • �//�� •I� ��C '
NAME 1;gtA A—fif "H(b f?yCkGN� TO BE REMOVED TO BE RETAINED
ADDRESS ` r rY . . � TYPE OF ROOF COVERING
CITY a zI(Pln� r�"w 5T FISTING
PHONE(�D%� v I11 BUILT-UP ROOF
NUCENSE
MBER A PHA SHINGLES ❑
LICENSED CONTRACTORS DECLARATION -
I hereby affirm that I am Ilcensed under proviefors of Chapter 9(commenting with Section WOOD SHAKES ❑
7000)of DMslon 3 of the Business and Prolesslona Code,and my license a In full force and
effect.
a � 5�pgb SS ❑
License G Dc.Number
Data OT E ) ❑
' 31_ Contractor _
OWNER-BUILDER DECLARATION
I hereby allirm mat I am exempt from the Contractors License Lew for the follvM g reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to .
construct.after,rsuImprove,damollsh,orropelranyntrthate.priortoItsIseuanco,elmeproviethe B L;-/OF
applicant for arch permit to file a signed air any st that he Is sceneed p uance al ma pm+lsl the
of the Contractor.License Law(Chapter S(commencing whh Section 7000)of Division 3 of Ne A Business end Protesslons Code)or that he Ie exempt therefrom antl the beals for the alleged 7ASPHI E u
exemption.Any violation d Section 7031.5 by any epphcent far a permit subjects the applicant to
a cMl penally of not more,than five hundred dollars($500).): R 1/ n
❑I,an owner of the property,or my employees with wages as melr ode rnmponsetion,willW WOOD SHA K C/ " 1 IlllrlrA
the work,and the structure Is not Intended or offered for safe(Sec.70",Business and Prof ss- /per U
ns Code The
License Lax,does not apply to an Owner of property
Wilds�
thereon,�ana wwhood are not ias Wcrcisd or offs himself
d for f or t If, h eo the building br or�rwemhatent WOOD SHINGLES y U/-
improves; I—IryG
Is sold whin one year of completion,the owner-Wilder will have the burden of proving that he did OTHER (SPECIFY) �❑
not What or Improve for Wribeso of sale.).
❑I,as owner of the property,em extiusivety,contracting wtlh licensed contractors to wnslnwt
the project(Sec.7004,Busimes and Professions Code.The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
appy,to an owner of property wflo Wilds Or mail thereon,and who contracts for such projects '
with a contractors)licensed pursuant to the Contractors Ocense Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑I em exempt under Sec. ,B&P.C.for Nle reason
Owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty Of perjury ore of the f slowing declaration:
❑1 have and will maintain a Cerddcate of Co sent to selfinsure for Workers Compensation, V J BUlldln
dQ
as provided for by Section 37W of the Labor Code,for the performance of me work for which MIs
permit Is Issued.
-11 have and will maintain Workers CompanseklW Insurance,as required by Section 3700 of I�� 00 Selsmlc
Me Labor Cade,for the performance of the work for which this permit Is Issued.My Workers
Man Ince carrier and Policy n mber are: I^ Total
Cant z policy No. (GV PERMIT AUTHORIZATION DATE
CERTIFICATE pF FJ(EM ON FROM WORKERS'
COMPENSATION NSUFul N.C.0(Thissectionsection need beed not completed permit If the peit Ie for one hundred colors($100)or less.) /
/)
I Cordy That In me pedomsnce of the work for which this permit Is Issued,I shall not em
(Thq%'
arty person In any manner so as to become subject to the Wokam'Comps radon Laws of oatiy All roc .,h ll be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date Applicant Inspection,I agree to r all new materials for inspection.
NOTICE TO APPLICANT: If,cher making this Cardgcale of Exemption,you should become applicant understa ds and ill comply with all non point
subject to ore Workers'Compensation provisions of the Labor Code,you mut forthwith comply
with such provisions or this permit shell be Warned revoked.. Source regulations.
I certlry drat I have reed this application and state that the above Inksmatl n is correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,and roe overt gs O aCl C. tter.
hereby aumohza representatives of this city to enter upon the ebcye-mentionec property for In-
specllon purposea.
(Wel agree to save,Indemnity and keep harmless the City of Cupertino against Ilabilldes,
judgments,costs and expenses which may In any way accrue against We City In consequence
of me granting of this permit. UR OF APPLICANT ATE
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