R-5221 PERMIT R_ 5 2�K]
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
•
WITHIN DAYS PERMIT ISSUANCE OR
WIT DANSS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
7 X
RESIDENTIAL COMMERCIAL OTHER
OWNERS HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME + roof assembly is required.
NO ❑ Initial I.C.B.O.A
ADDRESS EXISTING ROOF COVERING
PHONE Z Z NUMBER OF EXISTING COVERINGS
CONTRACTOR',SG
_-P l�G.C.�/Ys••" 4q'r� J/a{/yl- C/ TO BE REMOVl TO BE RETAINED
NAME
ADDRESS ,'g�O _ /� TYPE OF ROOF COVERING
CITY aZIP,
it?If o n EXISTING
PHONE GT/a BUILT-UP ROOF ❑
LICENSE
NUMBER GG , _ ASPHALT SHINGLES ❑
O
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is in full force and
effect. / b/
C l�0 WOOD SHINGLES P D
License Clens � Llc.Number O Y A M
Data Conirector BLU,D
OTHER(SPECIFY) ElOWNER LDER DEC RATION PROPOSED FEB ❑[p
hereby affirm that the am exempt from the Contractor's License Lew for the fallowing reason.
(Sec.construct,
It Business Improve and Professions Code: Any city or county which requires a permit to
applicnt,altsuch permit t file ish,or a signed air statement
re,he Iprior tos
issuance,alsorequiresprwesthe BUILT-UP ROOF C(fY �]I liUrtI�IIINU
applicant for such permit to Ills a signed statement that he Is licensed pursuant to ma provisions
of the ss and Contractor's License Lew(Chapter 9(commencing with Section 7000)of for the 3 of the
• Business and Professions Code)or that h Is exempt therefrom and the basis for the applicant
ASPHALT SHINGLES ❑
exemption.Any violation of than
five hundred
by any applicant for a permit subjects the eppllceni to
e dull penalty of not more then live hundred dollars l( : a�
❑I,as owner of the property,or my employees withh wages WOOD SHAKESs as their Bole compensation,will do ❑ I
the work,and the structure Is not intendedsLaw or offered for sale n ow er of Business and Profen
aeons Code:The Contractor's License Law does not rapply through
an owner of properly who builds or WOOD SHINGLES ❑
Improves thereon,and who does such work himself or Nrouoh his own employers,Improvement provided that
such improvements are not completion,
leb n,orow offered for leer. ill however,the bulltling viImprovement
is notsold bull or
prove for purpose
sthe ownerbulltlerwlll have the buten of proving that he tlltl OTHER(SPECIFY)
not build or Improve for purpose Of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct �09�
the project(Sac.70",Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O. REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B&P.C.for this reason
Owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, ��� Building D
as provided for by Section 3700 of the Labor Cotle,for the performance of the work for which this �
permit is Issued. L' l ,2 Seismic T�
have and will maintain Worker's Compensation Insurance,as required by Section 3700 of L [ TI
lh Labor Code,for the performance of the work for which this permit is Issued.My Worker's
'Compensation Insurance carrier antl Policy number are: Total
Carrier L/� ^— - 4 Policy No.N��30/ -v PERMIT AUTH RIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMP If the permit
INSURANCE 100)o n 01
(This section need not be completed If the permit la for one hundred dollars($100)or less.) � V//'
42
1 certify that In the performance of the work far which this permit is Issued,1 shall nal employ
any person In any manner so as to becometubject to the Wor' rs'Comp cation Laws of CaH- All roof^shall be inspected prior to any roofing material being
Iornia. installed. If a roof is installed without first obtaining an
Date Z Applicant inspection,I agree to remove all new materials for inspection.
PPIfICANT: It,after
subject toEth Worrkers'Comprnaetlon provisions behelL born Cotle,yyoou mustfoinwith omply Applicant understands and will comply with all non point
with such provisions or this permit shalQbe doomed 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 rotating to building construction,and All roof coverings to be class"C"or better.
hereby authorize representatives of this clty to anter upon the above-mentioned property for In- n
sppurposes.
(We)
(We)agree to save,expenses
and keep harmless the Clry ai Cupertino against liabilities,
• ofjudgments,e gran coats and expenses which may In any way accrue against said City In consequence �
of ma granting of this permit. SIGNATURE,0F APPLICANT �I�
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