R-5607•
PERMIT R_
5607
APPLICATION FOR CITY of CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
,,[�
/00 ;Z l/�e� / J,-7 '
RESIDENTIA COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
�
J
YES ❑ It yes I Understand that a Class A
NAME B/6 of Ze�,[ooI
assembly is required.
N U Initial I.C.B.O. a
Gil e,6���
EXISTING ROOF COVERING
ADDRESS J ?7 gejf�C
,�u..t
PHONE l 5?4—a—
NUMBER OF EXISTING COVERINGS
CONTRACTOR'S t )
TO BE REMOVED ` TO BE RETAINED
�,
NAME
ADDRESS
TYPE OF ROOF COVERING
CITY&ZIP
EXISTING
PHONE I Y� ) �Z�SG�->�,gQU
❑
BUILT-UP ROOFLICENSE
NUMBER /
ASPHALT SHINGLES ❑
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license is In full force and
effect.
/7
License Class Llc. Number l � r�14-01
WOOD SHINGLES ❑
S—_�S � /!i �jJ
OTHER (SPECIFY) ❑
��/
Data -BUILDtor %7
OWNER theLDER DEC's Lice Lew for the following reason.
hereby affirm Ines I am exempt from the ore
PROPOSED j`'
Business and Professions Code: Any dry or caunry which requires
(Sec. e: Any or county permit to
construct, It
apnecunLor su Improve, ish, or any he prior to its Issuance, also requires
BUILT-UP ROOF ❑
to file theprvithe
for such permit to flaw a that he Is licensed o p
a signed to the provolone
License Law) 000) of
of the Co (Chapter 0 (commencing with Section 7000) of
of the 3 of the
/
ss an Pre
or that for the
Business and Professions Coda) or the. he is exempt therefrom and the basis for the alleged
ASPHALT SHINGLES
exemption. Any violation of Section 7031r byany applicant for a permit subjects the applicant to
Yra'Y
e civil penalty not more than five hundred dollars (h ):
WOOD SHAKES
a wag
1, as ownerofthe property,or employees wages (sec. their compensation, will do
❑
tmy eemployeeswith
the work, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Prole9-
slons Cade: The Contractor's License Law does not apply to an owner of property who builds 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. It, 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.).
01, 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 doe. 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 contractions) licensed pursuant to the Contractor's License Law.
PROVIDE MFGR. INSTALLATION SPECS.
[3I am exempt under Sec. ,B & P. C. for this reason
Owner Date
APPLICATION DATE
VALUATION
PERMIT FEE
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
01 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 Code, for the performance of the work for which this
per It al
have antl will maintain Worker's Compensation Insurance, as required by Section 3700 of
N.r
Seismic
t La or Code, for the performance of the work for which this permit Is issued. My Worker's
'Compensatio�n
///�/,..
7l� •'��
�334e .
,IInsuraanco ce�rrla�r end Polic�y%'umber ere:
r I uh
Total
Carrier — /�tYf�f Policy No.
P I /A THORI ION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed II the permit Is for one hundred dollars ($100)100) or lase.)
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
forma.
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, atter making this Certificate of Exemption, you should become
Applicant understands and'will comply with all non dint
PP P Y P
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
with such provisions or this permit shalGbe 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 be class or ter.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes.
(We) agree to save, Indemnify and keep harmless the City of Cupertino against liabilities,,87
judgments, costs and expenses which may In any way accrue against said City In consequence
SIG A RE F A DA TE
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