R 5748 PERMIT R_ 5748
APPLICATION FOR CITY OF CUPER71NO NUMBER
REROOF PERMIT . INSPECTION DIVISION PERMIT EXPIRATION
(408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
n -1 X 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING
10S11IESS n AJ �IL/-L �-VL + �
Iv RESIDENTIAL COMMERCIAL OTHER
OWNER'S - HAZARDOUS FIRE AREA
1)- T YES ❑ If yes-I understand that a Class A
NAME C.- V roof assembly is required.
yy,y NO ❑ Initial—, I.C.B.O.N
ADDRESS-3A/4 4 EXISTING R RING
PHONE 1_)E3 — I I NUMBER OF EXISTING COVERINGS
CONTRACTQR'S '/(� �1
NAME IF/IFki T�k� l u>y F SC lr--�Vr 9S 1 S TO 13E REMOVED TO BE RETAINED
ADDRESS O Z 4 io6 f� S r S y TYPE OF ROOF COVERING
CITY&ZIP
EXISTING
PHONE- u BUILT-UP ROOF
NUMBER
ICENSE / 1(O r S ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES ❑.
7000)of Division 3 of the Business and Professions Code,and my license is In full force and
effect C-3�91 / WOOD SHINGLES
License Class Up.Number " /
Dare /a" - y Contractor. OTHER(SPECIFY) ,, / ❑
OWNER BUILDER DECLARATION PROPOSED �Y
hereby affirm that am exempt from the e: Any city License Lew for the following reason.
(Sac.7037.8,Business and Profedemolish,
or rep Code: Any city or or to It which requires a permit to
conscnt for alter,Improve,to file asigned staair eny mentrthate,priortoileIssuance,pursuant
reproves the BUILT-UP ROOF
applicantforsuch permit to file aslgnetlr statement(commencing
it licensed pursuant tithe provisionsoth
of the Contractor's Usines Law(Chapter B(commencing with Section 7000)of Division the 30l the
•
exemption.
and violation of Code)or that he IS exempt therefrom and the brats for the applicant
to ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the epplirenl to
e civil penalty of not more Ihatf'll0d'Hummetl do8smt"Sol
❑I,as owner of Ila proper my emp yes with wagas the I compensation,will do WOOD SHAKES
the work,antl the structure Is ,and. to8 d for ad(Sec. Business and Profes-
sions Code:Tha Conlrector'a18 se Lew does o apply n ow r f roperty who bullae or WOOD SHINGLES
Improves thereon,end who tlp�a ch work himself or through his o ployees,provided that ❑
such improvements ere not "ito gqHaher roof $41�.11�oyvayee Iltll or Improvement
Ie said withlnoneyear ofcom Iran,tffdow5er- Id wd he r not provingthat he did OTHER(SPECIFY) ❑
not build or Improvo for purp of sale.).
❑I,as owner of the props em exclusively contracting with lice a onlractors to construct
the project(Sec.7044,Busin ss and Professions Code:The Contrac or' License Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property H Vida or improves thereon,and who cc tracts for such projects
with a contrechi licensed l u4ntieirwLintm�tn±s I inalse
❑1 am exempt under Sec. &P.C.for this reason PROVIDE MFGR.INSTALLATION SPECS.
ownerDare
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION . PERMIT FEE
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, 0 Building
/07
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this ` 0
pe�raJI is Issued. .Fl�l 96)0 Seismic 610®I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
thNLbbar Code,for the performance of the work for which this permit Is Issued.My Workers
Compensation Insurance arrraUµiS number are: Total
O 7r 8
Carrier '5r� r
Pa11cyNoyi060 a" PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed If the permit Is for one hundred dollars($100)100)or IaseJ Z
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
Data Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,alter making this Certificate of Exemption,you should become
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply Applicant understands and will comply with all non paint
with such provisions or this permit shalt be deemed revoked. Source regulations.
I certify that I have read this application and state that the above Information Is Correa.I agree
to comply with all city and county ordinances and state Tawe relating to building conatructlan,and All r coverings CO be SS° r better.
hereby authorize representatives of this city to enter upon the above-mentloned property for ad
sp(We) purposes. q� M �� /�"� "r r/
(We)agree to cave,expenses
and keep harmless the City of al Cupertino Ci y In col liabilities, alZ 1 c 111 I ./ o
judgments,costs and expanses which may In any way accrue against sold City In consequence
of granting of permit. SIGNATURE OF APPLICANT DATE
• 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