R-5552•
•
OFFICE COPY
s RR- 5552_J
APPLICATION FOR - clry of cuPeRTINo NU
' 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
`/'�1 //�/
1 I�-k T, 1-���
HAZARDOUS FIRE AREA
YES ❑ If yes - I understand that a Class A
�� 1
NAME
tiII)CL.� l Q/V`,
roof assembly is required.
NO Initial I.C.B.O. q
^
EXISTING ROOF COVERING
ADDRESS r\j'��
/
NUMBER OF EXISTING COVERINGS
PHONE
)
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAME '
ADDRESS/9Q� �� V V
TyY.P�t�O CO RI
CITY & ZIP 0r - -
{/��+
EXISTING
'J
PHONE 9(.2)— to
BUILT-UP ROOF ❑ 1
_
LICENSE ' I
NUMBER O�
ASPHALT SHINGLES ❑
-
LICENSED CONTRACTORS DECLARATION
I hereby affkm that I am licensed under provisions of Chapter g (commencing with Section
WOOD SHAKES
]000) of Division 3 of the Business and Professions Code, and my license Is In full force and
affect.
O
WOOD SHINGLES ❑
License Class Lie Number
/,� - _
Date Contractor
OTHER (SPECIFY) ❑
OWNER -BUILDER DECI-ARATIOV
I hereby affirm that I am exempt from the Contractor's License Lew for the knowing reason.
PROPOSED P4 ID
(Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to
construct, alter, Improve, demolish, or repair any structure, prior to Its Issuance, also requires the
BUILT-UP ROOF T�
applicant for such permit to fila a signed statement that he is licensed pursuant to the provisions
of the Contractors License Lew (Chapter B (commencing with Section ]000) of Division 3 of the
Cp'y
Business and Professions Code) or that he Is exempt therefrom and the basis for the alleged
ASPHALT SHINGLES Uh ❑
by any applicant for a permit subjects the applicant to
exemption. Anyviolationnot on of Section hundred
e civil pastry of not more than five hundred
(h
��J*
y
yeesrs
❑ I, as owner of the property, or waged sole compensation,sandwill
employees with wages exec.
WOOD SHAKES ❑
to for sale 7 Business and Profes-
the work, and the is not intended ores ow s -
n owner of or
Contractors d Licence Law does s not apply to an ownere property who
sions Cotle: The ontracto not
WOOD SHINGLES ❑
provided t
improves thereon, and who does such workhimselffor or through his own employees, provided that
, a
such improvements are not intended or offered far seer. If,ill however, the or Improvement
/ /1 cz
enbuilding pr
Is Completion the OwnerOuilderwill have the burden of proving that he tlltl
OTHER (SPECIFY) ❑ ,fJ
notsold bull or prove for
not build or Improve for purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to constructq
the project (Sec. ]1144, Business and Professions Code: The Contractors License Law does not
PROVIDE I.C.B.O. REPORT NO. / 3
apply to an owner of property who bulks or improves thereon, and who contracts for such projects
with a contractor(s) licensed pursuant to the Contractor's License Lew.
PROVIDE MFGR. INSTALLATION SPECS.
❑ I em exempt under sec. .B & P. C. for this reason
Owner Date
APPLICATION DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
Bullt
hereby affirm under penalty of perjury one of the following sure for
Workers ❑ f have and will maintain a Certificate of Consent to self -Insure for Workers Comp this
as provided for by section 3100 of the Labor Coda, for the performance of the work for whichhich this
f9
g
pe�rm�+a Issued. and of
� end will maintain Worker's Compensation Insurance, as required by Section
/� q p/J
/ / /
I
/7/ ! OL/ /
( (i
Seismic
.—,va
Worker's
th Labor Code, 1 r the performance of the work far which iNe permit Is Issued. My Worker's
Total
Compensation In ranee carrier andTy number are:
Carrier Policy No. �/ �5� �/
PERMIT AUTHORIZATION
DATE
CERTIFICATE EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.
(This section need not be Completed If the permit is for one hundred dollars ($100) or less.)
I certify that In the performance of the work for which this permit is issued. 1 s ell not employ
any person In any manner so as to become subject to th Wo u ompensar Lawn of calf
All roofs shall be inspected prior to any roofing material being
fornle.
installed. If a roof is installed without first obtaining an
Dale O Applicant "`��
inspection, I agree to remove all new materials for inspection.
sionthis { become
NOTsubject lI.the OWorrkers 0oae Exemption,
Applicant understands and will comply with all non point
Compensation provier
. of the Lahm mustforthwith comply
with such provisions or this permit shall be doomed revoked.
Source regulations.
I certify that 1 have read this application and state that the above Information Is correct I agree
to comply with all city and county ordinances and slate laws relating to building construction, and
All roof co gs class"C" rbetter.
hereby authorize representatives of this City to enter upon the above-mentioned property for in.
spection purposes.
(
O 7
(We) agree to save, indemnity and keep harmless the City of Cupertino against liabilities,
/
judgments, costs and expenses which may in any way accrue against said City in Consequence
SIGNA URE OF PLICANT DA E
of the granting of this 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