R 5232 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMB R R' 5232 __
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
•
WITHIN DAVE PERMIT ISSUANCE OR,
WI DAYSS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
3 0("'i RESIDENTIAL COMMERCIAL OTHER
OWNER'S . HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME roof assembly is required.
NO ❑ Initial I.C.B.O.#
ADDRESS _ EXISTING ROOF COVERING
PHONE , r /Lh NUMBER OF EXISTING COVERINGS
CONTR R' //�/ � /'�
?—M� TO BE REMOVED / TO BE RETAINED
NAME_\ Y VJ4fJ I C/
ADDRESS� UiT n I (� TYPE OF ROOF COVERING
CITY 8 ZIP`'f s Lc�tdc/1A, A 1 I EXISTING
PHONE 4 J BUILT-UP ROOF
LICENSE !�
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATIONC�
I hereby affirm that I am licensed under provisions of Chapter 6(commencing with Section WOOD SHAKES LL
7000)of Division 3 of the Business and Professions Cotle,and my license Is In full force and
effect. /� WOOD SHINGLES El
License Clef I.K.Number U
Oats Can raatar OTHER(SPECIFY) ] A 9 D
OWNER-BUILDERtDECLA TI �
1 hereby a#rm th t I am exempt from the Contractors License Law lo!the following re eon. PROPOSED NOVq�(��
(Sec.7031.5,Business and Professions Code: Any city or county which requlrae a permll to N `� 11, I .7
construct,alter,improve.demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF
applicant for such permit to Me a signed statement that he Is licensed pursuant to the provisions Tv
of the Contractor's License Law(Chapter S(commencing with Section 7000)of Division 3 of the CI I t Ut- W rrn ulvU
• Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES ❑
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of not more than five hundred dollars($500).):
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profee-
sions Improv nth The Contractors License Law does not orthro through o an owner
property who probuilvided
or WOOD SHINGLES ❑
Improves thereon,and who does deco work himself or through his own employees,Improvement ant
such Improvements one year
are not completion,
or owner-builder
for leer.ill however,the en of
or ImprovementIs sold
not build or
prove for purpose of
owner-builtlar will have the burden of proving that he did OTHER(SPECIFY)
- "
not build or Improve for purposo of sale.).
❑I,as owner of the property,em exclusively contracting with licensed contractors to construe UJ
the project(Sec.7064,Business and Professions Code:The Contractors License Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts far such projects
with a contractor(s)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPEC
❑1 am exempt under Sec. ,B B P.C.for this reason
Owner Date APPLICATION DATE VALUATION MIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑l have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Building
s
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this n�
permit or Code. IA SI f••tfl#� SBISB'IIC
❑e have and will maintain Workers Compens lion Insurance,as required by Section 3700 of
the Labor Cade,for the performance of the coo for which this permll is Igsued.My Work r'e ry
Co su ar r entl Policy num rare: y"r,.�J 7 / I,i/t� Total T
Carrier Policy0. R /I I G PERMIT AUTHORIZATION DATE
CERTIFICATE EN EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed If the permit is for one hundred dollars($100)or less.) �3---056 I certify that In the performance of the work for which this permit is Issued,I shale not a toy !/ Y�
any person In any manner eo as to become subject to the Workers' 71t,penaall Lawr OfI t I All roofs s I be inspected prior to any roofing material being
Ionia' I installed. If a roof is installed without first obtaining an
Date
�APptiCanl ^" inspection,I agree to remove all new materials for inspection.
subject to Ea Work s'Compeneelecnprovisionsofthelcate of LaborCode,yoiumustforthweltlhbecome comply Applicant understands and will comply with all non point
with ouch provisions or this permit shell be deemed revoked, Source regulations. . '
I Certify that l have road this application and state that the above Information Is correct,I agreeto ' y
hereby authorize
representatives
ordinances to entet upon the
cove-mentioned
All roof CDV be 5 "Q.°i better. 13
hereby comply
with
hlze city and county of than city to enter upon Ire Bing to building
construction,property for In.and
JJ
spection purposes.
/1�
(We)agree to save,Indemnify and keep harmless the City of Cupertino epaenst liabilities,
judgments,costs and expenses which may In any way accrue against said City n consequence
othe granting othis permit. SIGNATURE OF 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 CnPV