R-5505 (2) APPLICATION FOR CITY OF CUPERTINO
NUMBER PERMIT
R" 5505
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
• GRESS 1BO DAYS FROM LAST CALLED INSPECTION.
BUILDING ADD
I-oq
.J ilpe- 14
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
VES E] If yes-I understand that a Class A
NAME Sy h e roof assembly is required.
NO � Initial LC.B.O.N
ADDRESS r0 �{- EXISTING ROOF COVERING
PHONE J y NUMBER OF EXISTING COVERINGS
CONTRACTS 1 �—
NAME ! ,fC(q � &!%n NC TO BE REMOVED==41e 5TOBERETAINED
G �I TYPE OF ROOF COVERING
ADDRESS 7 / �0 CN ,CY �� /7- EXISTING
CI 8 ZIP / / / ,e�'L
PHONE S'(z9) 7 70 O 3a,-)— BUILT-UP ROOF ❑
LICNUM ER ASPHALT SHINGLES ❑
LICENS D CONTRACTORS DECLARATION
I hereby affirm that I ain 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
Dfect.
Q WOOD SHINGLES ❑
License Class Uc.NumOer 0+
Date��N-y 2 convector - syZ_ G OTHER(SPECIFY) El
OWNER the
DECLARATION PROPOSED
hereby affirm that am exempt from the e: Any city License Law for the requires
a reason.
(Sec.7ct,alt Business and Professions Code: Any city or county which requires a permit to
construct,alter,Improve,to file signrepair any ed statement
prior toils issuance.also requires the BUILT-UP ROOF
of the
for each permit to file a signed statement that he it IlCeroed pursuant t0 the provisions
of the ss and tPro License Lew(Chapter 9(commencing therefrom
Section 7000)of for the 301 the
. Business entl violation of COtla)or that he Is exempt therefrom end the beats for the applicant
to ASPHALT SHINGLES
exemption.Any violation Of Section 7031r by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred employees
dollars(h wag): WOOD SHAKES
❑I,as owner of the property,or to employees with wages as their sola compensation,will Profes-
sions ❑
the work,end the structure Is not InsenLatl ores nota for sale(Sea er of Buslneea entl uildsoimprov improves
The,an who
es such Lewdi self Or apply to
hiso own
property pho rovide that WOOD SHINGLES ❑
Improves thereon,entl who tloes such work himself at through his own employees,Improvement provided that
such improvements aro not completion,
leb n,or offered for leer. ill however,the en of pr or Improvement
Is sold not
or
prove for purpose
sail owner-builder will have the burden of proving that he tll0 OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
1,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,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 contracror(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&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 declaration:
❑I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, Building
as provided for by Section 3700 of the Labor Cotle,for the performance of the work for which this '
permit is Issued. ® DO Seismic❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 01 r`//9
the Labor Code,for the performance of the work for which this permit is Issued.My Workers ,y
r Compensation Insurance�ca�rrier and Policy number are: / yr Total
411111 Cerrler4f yn7 yIy"'i PolicyNc11,k1OZclbP-5d1 RE&IT�AWORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O r
(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 1 Is permit is issued'I shaft not employ
any person In any manner so as to become sublact f workers compensation Laws of call. All roofs shall be inspected prior to any roofing material being
fornia. 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 a ertllicate of Exemption,you should become Applicant understands and will subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP comply P Y with all non Point
with such provisions or this permit shall),be deemed revoked, source regulations.
I certify that I have read this application and state that the above information Is correct.)agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof V rl gs to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned properly for In-
spection purposes.
(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 SIG OF APPLICANT l
of the 9r of 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