R-5725 PERMIT R_ 5 7 2 5
APPLICATION FOR CITY OF CUPERTiNO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
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
RESIDENTIAL_COMMERCIAL OTHER
OWNER'S - HAZARDOUS FIRE AREA
1 YES E] If yes—I understand&of a Class A
1
NAME �y rod asserrtdy S required.
NO ❑ Ir1Aal I.C.B.O.i
ADDRESS 1g"l WLliz4oki ✓L•i ivc42'dm G.%AI4— EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTORS
pl�l +/ P Ta/1 �'K�.�• TO BE REMOVED I TO BE RETAINED
NAME
ADDRESS TYPE OF ROOF COVERING
CITY a Z P 2co'�7 l�aL��t2 !Jn•�_9_ a�1j1� "i51 I I XI N
PHONE `J — - BUILT-UP ROOF ❑
Cov4-a. Uc A I D
NUMBER $ O ASPHALT SHINGLES
LICENSED under
Fts OECf Chapt r 9(commencing J& 0 6 ANGST
hereby affirm that em usi n ss, under fessions of Chapter B ,IsInwith Section
and WOOD SHAKES
]000)of DlNebn 3 0l dro Business and Professions Cada,and my Ikenee le In lull force entl
effect. WOOD SHINGLES I�
Los.Clause C..i Lk.Number �Ti�l - CI I Y ur- wrcn l urU
Date (01i Contractor G>�i Q OTHER(SPECIFY) ❑
OWNER BUILDER DECLARATION PROPOSED
I hereby affirm that I am mempt from the Contractors License Lew for the following reason.
(Sec.7031.5,Budness and Prolesalor,Code: Any city or county which roqulroc a permit to
construct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,alsormulreethe BUILT-UP ROOF ^^
applicant for such permit to lila a signed statement that he Is licensed pursuer;to the prodsdne ❑ k.Fl 1n✓
of Me Contractors License Lew(Chapter a(commencing with Section]000)of Division 3 of the crklk
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES 9;j ,Q,,,yr
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the appicant to (T �Ye.51 N 'a
a civil penalty of not mere then five hundred dolume($500).):
01,as owner of the property,or rtry,employees IRM wages as Melr We compersaum,wig do WOOD SHAKES ❑
the work,end the structure Is W Intended or offered for sale(Sec.7044,Dullness and Profes"
elm"Code:The Contractors Lbenea Lew does not appy to an owner of property who bulls or WOOD SHINGLES
Improves thereon,and who does such work Minoan or through his own employees,proved that ❑
such Improvements are not Intended or offered for sale.If,however,the building or Improvement
Is sold Mhlnone year of completion,Me ownerbullder will have the burden of provingthat he did OTHER (SPECIFY) ❑
not bulld or Improve for purpose of sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to construct
III project(Sec.7044,Business and Professions Cada:The Contractors License Law doss not PROVIDE I.C.B.O. REPORT NO. N A•
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a cootnc;or(s)licensed punuent to Me Contractors License Law. PROVIDE Ml INSTALLATION SPECS.
E]I am exempt under Sec. - ,0 6 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following dederetion: /
❑I have am will mountain a Cerefoate of Consent to self-insure for Worker's Compensation, Building Its provided for by Section 3700 of the Labor Code,for the performance of the work for which the I / � 00
permit is Issued. Workers Compensetlon lnwrertcaLP/ p q Seismic
yo.lhave andwill rrelmain ,as required by Section 370001 - D
the Labor Code,for the performance If Me work for which this permit is issued.My Workers
CompamplikIn Insurarwe carrier and Pdlcy number are - Total j&4
carder UjizbK— Pmlcy No, I a❑41Y PERMIT A THORIZATION DATE
CERTIFICATE OF EXEMP7l FROM WORKERS'
COMPENSATION INSURANCE
(I section need not be completed 8 the permit b for one hundred dollen(5100)or leas.)
I cartity that In the performance of Me work for which this permit is Issued I shall not employ
any person In any manner so as to become subject to the Workers'Compensauon Laws of Call- All roofs shall be inspected prior to any roofing material being
fomla. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Cedfficete of Exemption,you should become Applicant understands ancomply non lit dtandd will I with all point
subject to the Workers'Compeosatlon provisions of the Labor Code,.you must forthwith comply
with such provisions or this perms su lcbe deemed revoked. source regulations. -
I rarity,that I have read this applicalbn and state that Me above Information is correct.I agree
to comply with all dry and county ordinanoe,and state laws relating to bulltling construction,and! All roof coverings to be class" "or better
hereby authorize reprosimi LLrea of this city to enter upon the ammankned property for In-
spectos
on purpes. (� /J
(We)agree to save,Indemnify end keep harmless Me Cry of Cupertino agQalrat liabilities,
d
judgments,costa and which may In sry,way accrue against said City In consequence I NATLIB OF APPLIC DATE
of the granting of this permit.
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: - BATTENS: - FINAL:
INSP. RATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION '
OFFICE COPY