R-5402OFFICE COPY
PERMIT R-5402,
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION •
REROOFPERMIT (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
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/
✓COMMERCIAL
RESIDENTIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
YES ❑ understand ThatClass A
NAME CDr�'� �Dll.��t�
roof assemble
y' srequired..
NO ❑ Initial I.C.B.O. n
II (' LA �{ kxSi+-rd1 'Ar•
EXISTING ROOF COVERING
ADDRESS
1
PHONE q45-6100
NUMBER OF EXISTING COVERINGS
Cl,
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAME
TYPE OF ROOF COVERING
EXISTING
ADDRESS29 c 1
CITYBZIP �-`�'f I J.J. ISflo
Z1 q —6(YO
PHONE
BUILT-UP ROOF ❑
CENSE
NUMBER 6 9y
ASPHALT SHINGLES ❑
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
]000) of Division 3 of the Business and Professions Code, and my license is in full force and
effect. [
s Lic. Number C Vil81Z
License Class
WOOD SHINGLES ❑
Date /3� �`� Contractor ., �++r JJ•-Sc+1%r -
OTHER (SPECIFY) P A I D ❑
OWNER -BUILDER DECLARATION
hereby affirm that I am exempt from the Contractor's License Law for the following reason.
PROPOSED SEPI
4A
(S. ]031.5, Business end Professions Code: Any city or county which requires a permit to
ac
construct, alter. improve, demolish, or repair any structure, prior to its issuance, also requires the
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
BUILT-UP ROO
y OF
of the Contractor's License Law (Chapter 9 (commencing with Section ]000) of Division 3 of the
Business and Professions Code) or that he Is exempt therefrom and the basis for the alleged
Section 7031.5 by for the to
_
LUN
ASPHALT SHINGLES EH N(y" f-{O�r,
exemption. Any violation of any applicant a permit Subjects applicant
a civil penalty of not more than five hundred dollars ($500)J:
WOOD SHAKES
I, as owner of the property, or my employees with wages as their sole compensation, will do
the work, and the structure is not intended or offered for sale (Sac. 7044, Business and Profes.
builds
sions Code: The Contractor's License Lew does not apply to an owner of property who or
WOOD SHINGLES
�O
Improves thereon, and who does such work himself or through his own employees, provided that
such Improvements are not intended or offered for sale, it, however, the building or improvement
9
Is sold within one year of completion, the owner -builder will have the burden of proving that he tlld
OTHER (SPECIFY) 1.9'
not build or improve for purpose of sale.).
17
❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct
the project (Sec. 7044, Business and Professions Code: The Contractor's 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 contractors) licensed pursuant to the Contractors License Law.
PROVIDE MFGR. INSTALLATION SPECS.,
C]I am exempt under Sec. ,B 8 P. C. Mr this reason
I
Owner Date
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION
PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
1 have and will maintain a Certificate of Consent to self -Insure for Worker's Compensation,
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
Soo
Bulldln
permit Is Issued.
9/J"17
/
$elSfTllc
[-]I have and will maintain Worker's Compensation Insurance, as required by Section 3700 of
the Labor Code, for the performance of the work for which this permit is issued. My Worker's
Total
Compensation Insurance terrier and Policy number are:
Carrier Le510✓� Policy No. 0?
PERMIT PERMIIITTAAAUUTH�ORIZATION
DATE
CERTIFICATE OFCOMPEN COMPENSATION SURANON MWORKERS'
COMPENSATION INSURANCE N.C.
,;``IF
(This section need not be completed if the permit Is for one hundred dollars ($100) or leas.)
VV'� •' 1
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 Workers' Compensation Laws of Cali.
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.
NOT CE Tbecome
subject IO theOWorrkers' C mpeAPPLICANT, Insati n prolviafter sionls ofe
ethe Labor Code, you must foMwshoullitth comply
Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked.
S0 Ce 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, end
Allo be'class "C" or better.
hereby authorize representatives of this city to enter upon the above-mentloned property for In.
spection purposes.
9' Q
(We) agree to save, indemnity and keep harmless the City of Cupertino against Ilabllltie
I
judgments, costs and expenses which may In any way accrue against said CityIn consequence
ATE
of the granting of this permit.
PRE -INSPECTION:
PLYWOOD: -
IN -PROGRESS:
INSP. DATE
INSP. DATE
INSP. DATE '
TEAR OFF INSPECTION:
BATTENS:
FINAL:
Y 1
INSP. DATE
INSP. DATE
INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY