R-5445w
W
OFFICE COPY
PERMIT
5445
APPLICATION FOR CITY OF CUPERTINO NUMBERR_
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (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
Z'6?/7 P/AcG
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
YES_. If yes–. understand that a Class A
NAME I'
S_ roof assernbty is required.
NO Initial I.C.B.O. #
EXISTING ROOF COVERING
ADDRE�R 00
NUMBER OF EXISTING COVERINGS
PHONE
CONTRA TO 'S
TO BE REMOVED - TO BE RETAINED
NAME IIi/11�Y�
ADDRESS S
TYPE OF ROOF COVERING
CITY & ZIP
EXISTING
Z-
Z
PHONE
BUILT-UP ROOFLICENS❑
-O—,
NUMBER Z
ASPHALT SHINGLES ❑
LICENSEDdunderCONTRACTORS DECLARATION
hereby affirm that em licensed Pr provisions of Chapter 9 (commencing with Sectionnd
WOOD SHAKES 7,
9000) of Division 3 of the Business entl Profasaione Cotlo, and my license Is In full force entl
and
affect. 3T L„
WOOD SHINGLES ❑
License Class Uc. Number
OTHER (SPECIFY)In ❑
Date � Contractor
�
NPR -BUILDER DEC RATION
ROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec. 7031.5. Business and Professions Coda: Any city or county which requires a permit to
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the
BUILT-UP ROOF /b�
applicant far such permit to file a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
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 (8500).):
01, as owner of the property, or my employees with wages as their sola compensation, will do
WOOD SHAKES
the work, and the structure Is not intended or offered for sale (Sec. 7044, Business and Profes-
alone Code: The Contractor's License Law does not apply to an owner al property who builds or
WOOD SHINGLES ElImproves
thereon, and who tloes such work himself or through his own employees, provided that
such Improvements are not Intended or offered for sale. 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) ❑
not build or Improve for purpose of sale.).
❑ I, as owner of the property, em 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 contractor(s) licensed pursuant to the Contractor's License Lew.
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
p D
A
I hereby affirm under penalty of perjury one of the following declaration:
❑ I have and will maintain a Certificate of Consent to selMnsure for Worker's Compensation,
1' D
Building
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
permit is
havean
t have end will maintain Worker's Compensator, Insurance, as required by Section 3700 of
9.5
FI
Seismic❑
the Labor Code, for the performance of the work for which this permit is Issued. My Worker's
'Compensation
C1
lO (1
O
Total
Insurance carrier and Policy number are: `
Carrier C I IT Policy No.� /
PERMIT AU HO R I
DATE
CERTIF�XEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(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 this permit is issued, 1 II not employ
All roof^ shall tWinspdcted prior to any roofing material being
any person In any manner so as to become subject to the Worker ' Compen All of cau-
formDate. —Z�
installed. If a roof is installed without first obtaining an
Date pllcant
inspection, I agree to remove all new materials for inspection.
y
NOT aubecct bPTO the Wmkeres' CompeANf fnsata`o provisions nis fttheflcatLabaT odemyou must fonhwlltlhbcomply
Applicant understands and will comply with all non point
with such provisions or this permit shalflbe 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
All roof coverings to beAss"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
purposes.
Of
�I �I
(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
AUR PPLICANT DATE
of the granting of this 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