R 5251 APPLICATION FOR CITY OF CUPERTINO
NUMBER PERMIT
R- 52 51
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF'PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS ) //�
/Q(„CJ RESIDENTIAL---ICCOMMERCIAL OTHER
OWNERS - HAZARDOUS FIRE AREA
� / YES ❑ If yes—I understand that a Class A
NAME �./� f assembly is required.
NO R_ Initial I.C.B.O.#
ADDRESS 'eI� EXISTING ROOF COVERING
PHONE — NUMBER OF EXISTING COVERINGS /
a CONTRACTO ^ ,
/J 1{ TO BE REMOVED TO BE RETAINED
NAME
ADDRESS Y /, J A ,,,o TYPE OF ROOF COVERi
CITY&Zip— _
'�..t'o4=-;V EXISTING
PHONE BUILT-UP ROOF ❑ �� I /
NUMBER ASPHALTSHINGLES ❑ /�� L�
LICENSED CONTRACTORS DECLARATION / L
hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES
7000)of Divalon 3 of the Business and Professions Code,and my license Is In full force and
affect WOOD SHINGLES ❑
Lice n6e Class `^�"" • Llc.Number `—"'� - _
Date a� contractor OTHER(SPECIFY) ❑ 6D Q
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Lew for the following r� PROPOSED rx V 21 1996
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to 4�LxrJglyl'f L6
construct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
• of the Contractor's License Law(Chapter S(commencing with Section 7000)of Division 3 of the CIT Vf ULIeL{I INV
Business and Professions Code)or that he IS exempt therefrom and the basis for the alleged ASPHALT SHINGLES .0
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500).):
E]1,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 Profes.
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑
Improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for eels.If,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY)
❑1,
not build or Improve for purpose of Bele.).
1,as
ea owner of the property,aman exclusively Professions Cod :T with Ilcensetls Licen e L to construct
not
the project(Sec.7044,pettyBusinesshand rImprov Code:The Contractor's License Law does not PROVIDE LC.B.O.REPORT NO.
apply is ntownerof property who builds orImprovesthereon,and who contracts for each projects
with a c m exempt licensed pursuant to the Contractor's License Lew. PROVIDE MFGR. INSTALLATION SPECS.
❑I em exempt under Sec. ,B 8 P.C.for This reason
Owner oats APPLICATION DATE VALUATION RMIT FEE
WORKER'S COMPENSATION DECLARATION
hereby and under penalty of perjury one of the following duce for Wo
❑ have and will maintain 37 a Certificate of Consent to self-insure for of the oCompeneatlon, BUl dln�
as provitl ray Section 3700 of the Labor Code,forme performance of the work for which this jp /� /4isx/� /.,7
permit aeuetl. Y OYY!!i
have antl will maintain Worker's Compensation Insurance,as required by Section 3700 of / Seismic
the abor Cotle,for the performance of the work for which this permit IB Issued.My Worker's
Compare n aura ce cerriPolicy n�smber are. �yo�767-9� Total 1g
Carrier ,,�K/lj Policy N.110171 PER UTHORIZATI DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed If the permit Is for one hundred dollars($100)or lees.)
I certify that In the performance of the work for which this permit Is Issued,I shall not employ
any person In any manner so as to become subject to the Worker' ompensation Laws o/call- All roofs shat a inspected prior to any roofing material being
forma' /J installed. a roof is installed without first obtaining an
Date IL Applicant inspectiopF,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certiflpp a of Exemption,Jou should become Applicant understands and will comply with all non point
subject tc the Workers'Compensation provisions of the C bor Code,you must forthwith comply pP p y p
with such provisions or this permit shaNba deemed revoked. Source regulations.
I certify that I have read this application and state that the above Information is correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,and Al of Coverings t be Class"C"or better. -
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
ep(We) purposes. _
(Wei agree to save,indemnify and keep harmless the City of Cupertino against liabilities,
ludoftgmenta,costa antl expenses which may In any way accrue against aeltl CItY In cmnaequence`
oitRegrantingofthispermit. SIGNATU O APPLIC NT 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