R 5745 PERMIT R_ 5 7 4 5
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
1 WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS - -
2\ �` � RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME roof assembly is required.
�) NO Initial- I.C.B.O.M
ADDRESS �� a trRR>�c�1 '� EXISTING ROOF COVERING
PHONEOt.�pj 5 NUMBER OF EXISTING COVERINGS
CONTRACTO 'S - -
NAME TO BE REMOVED TO BE RETAINED
ADDRESS ' �..� TYPE OF ROOF COVERING
CITY B ZIP �
PHONE \��`y\
BUILT-UP ROOF
LICENSE
NUMBER ASPHALT SHINGLES ❑ 6 '
LICENSEDdunderCONTRACTORS DECLARATION
hereby iaffirmnion That I am Business
licensed under Professions
ions of e,and a(commencing calif Sectionnd WOOD SHAKES
7000)of Division 3 of the Businaea entl Professions Cotla,entl my license la in full force end
effect.
WOOD SHINGLES ❑
License lees Lic.Number aL.7�/C1
OTHER(SPECIFY) ❑
Data Contractor P A I D
OWNER-BUILDER fromthContractor's
DECLARATION PROPOSED P' /9
I hereby affirm Bu that I am exempt from Professions the e: Any city or coua Lew for the linofoaming reason.'
(Sec.7031.5,Business end olish,orrep Code: Any city or county which re,also a permit toconstMAY ,S 4
appitc nt,alter,Improve,to file sign d stateny menthatstructure,Is licenseor to Issuance,also BUILT-UP ROOF `d' d /n11BgtKiil{TD
applicant for such permit to fila a signed statement that he Is licensed Sectio 7010,Or
the provisions
of the Contractor's License Lew(Chapter B(commencing with Section 7000)of Dlvlelon 3 0l the
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINOVI?S)f GUrcti l
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).):
❑1,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.
sions Code:The Contractor's License Law does not apply to an owner of property who Wilds 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 sale.If,however,the Wilding or improvement
Is sold within one year of completion,the owner-buitdar will have the burden of proving that he olid 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 Contractor's License Lew 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 em exempt under Sec. ,B 8 P.C.for this reason
Owner Dale
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
�'''
I hereby affirm under penalty of perjury one of the following declaration:
�i vided and will maintain a Certificate of Consent to sell-insure orma for Workers Compensation, Buildin �_
permit Is is for by Section 3700 o1 the Labor Code,for the performance of the work for which ihla `Il_'1, ►�GJ` (va/ qd\-If�Aq.�/TL g
permit la issued,
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of Seismic
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's
Compensation Insurance carrier and Policy number are: r�� TO
Carder .SYPf(6 'C1h.� 19)-A
Policy No. 9)-A 'd PERMIT AUTHORIZATIO DTE
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 peregn In any manner ea as to begeme eabject io the workers'compensatlan Laws of call- All roots s a be inspected prior to any roofing material being
Iornia. installed. If a roof is installed without first obtaining an
Dais Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO
It.after
making
Certificate u °should
subject to the Workers'Compensation provisions of the Labor Code,you mstforthwlhcomply Applicant understands and will comply with all non point
with such provisions or this permit shelf be deemed revoked. SOU ce regulations.
I certify that I have reed this application and state that the above Information le correct.I agree 1
to comply with all city and county ordinances and state laws relating to building consiructlon,entl All of coverings to eclass°ri��Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In
spectlon purposes.
(We)agree to save,indemnity and keep harmless the City Of Cupertino egalnst Ilabllllles,
judgments,costs and expenses which may In any way accrue against said CIry In consequence SIGNATUREO PLICANT DATE
of the granting of this permit.
PRE-INSPECTION: PLYWOOD: I GRESS:
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