R-5422 PERMIT R_
APPLICATION FOR CITY OF CUPERTINO . NUMBER 542-Z
.
INSPECTION DIVISION PERMIT EXPIRATION
REROOFPERMIT (406) 777-3226 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180.DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
:BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
—
OWNER'S ' / HAZARDOUS FIRE AREA
( /C�/ _,.y� VES ❑ N yes ,I unclerstands req tlat. Class A
NAME �/� �/ l/��l`/ /f/hhPPG//�'4� roof assernbly Is required.
r. -
NO
d� IrYtlal LC.B.O.Y
ADDRESS Sa/ /ZZ OI��T .�}C� EXl$IING ROOF COVERING
PHONE _ NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
e� TO BE REMOVED TO BE RETAINED
NAME
ADDRESS TYPE OF ROOF COVERING
CITY&Zip C2$ z_ ,,l�.r. coew/
C �+ EXISTING
PRONE 0 06/ 7 BUILT-UP ROOF ❑
LICENSE
NUMBER i' ASPHALT SHINGLES ❑
UC NSED CONTRACTORS DECLARATION
I hereby affirm that 1 am licensed!under provslons of Chapter B(canmencing with Section _ WOOD SHAKES
7000)of Dhusicn,5,ef the Rulara.s and Profession,Code,arb my license Ie In full force and
ems'"' -7b WOOD SHINGLES ❑
License Clave Uc.Number
OTHER(SPECIFY)OV7 ❑
Date Carl ��
Nom BUILDERDEC nse PROPOSED
hereby affirm Bu that em exempt from the Code:Comactor'scity or coup Lew ton the following reason. ,
(Sec.uct, It BImprovm end Pllaft, l rapraAny dry or county which requires a permit to
mmc nt alter,Improve,clannoto file asigned tat ementhat hstructure,Is licenseor to ldsuame,to theprovirequires the BUILT-UP ROOF' ^1/
of Me
far etch permit to flaw a signed statement that g h n end pursuant to the prw of the V
OI the ss shot Pro License Lew(Chapter h(commencing with Section]000)of for the 3 of the
exemption.
end violation
Code)or that he Is exempt antforam and the basis for the alleged ASPHALT SHINGLES
a chyli en.Arcot not more
of Section 7031.5 by any eppllcant for a permit subjects the applicant to
e dvil penalty of mato then five hundred employees
dollars with
wage WOOD SHAKES
❑Las owner of the property,or to ded oyree we wages as their sole compensation,will s-
the work,end Me structure Is rot Intended or offered for Bele(Sec,7014,Business antl Proles-
ebneesthThe,andwhodessuchLawdometrotapplyto genownerofployerrywhobuilds idedtor WOOD SHINGLES ❑
krprovee thereon,mv1 who does deco work hal for or .If,however,
am employees,Improvement provided Met _
such in :thin o enle are notcompletion,
Intended the
offered for leer. ill havethe the en of pr or Improvement
Is ntbuildo Improveerofmmpletofsthe owner-0ulltlerwlll have the Wrtlan of praAng that he tlM OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.). ,
❑I,as Owner of the property,em exclusively contracting with licensed wntrecicra to carstrud .
Me project(Sac.7044,Business and Protestations Code:The Contractors Llcenee Law does rot PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who Wild,orImproves thereon,and who contracts for such projects _
.with a contractors)licensed pursuant to the Contractors Ucenss Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 em exempt under Sec. ,B&P.C.lar MIs reason
owner Date
WORKERS COMPENSATION DECLARATION DATE VALUATION PERMIT FEE
_ '
I hereby still.under penally of perjury one of the following dedeation: Q�4 V,+a
0 have and will maintain a Certificate of Gooden[to seWnsure for Workers CornNnsaWn, Building/
ea proofed tar by Section 3700 o1 Me Labor Code,for Me performance of Me wad,for which this -
penNt Is issued. '
❑I neve antl will Workers Compensation Insurance,as required by Section 37W of 7,. 1� 6000 , 00 Seismic
the Labor r the work for which this permit Is Issued.My Workera f� /O
Compersa' I frier Icy number are: Total
Carrbr e Policy NGfQe,�'1_,9 PERMIT AUTHORIZATION DATE
CERn FICATE )F EAEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.00
(This dectlon need rot be completed If the penult is for one hundred dollars(S1 0)on lase.) � r-
I ceffity Mat In Me performance of the wok for which thls Of mJt is
issued,I.ahall not emplcy
ar pereon In any manner so u to become aLfi ect to the Workers'Comperselt Law•e of Cell All roofs Shall be inscted prior to any roofing material being _
installed. If a roof is installed without first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPUCANT: If,after making MIs Certificate of Exemption,you dhoulof become A aril understands and will comply with all non point
subject to the Workers'Compeneallon provisions of the Labor Cade,you must forthwith comply P ph p
with suds proveaions or this permit shell be deemed revoked. urce regulations.
I sanity that I leve reed Will application and state Mel the above Informelicn Is cartes[.I agree
to comply with on city and county ordnance.and state laws releung to beetling construdbn,and All r t c eri s to be class'C"or better.
hereby aumorize representatives of this city to enter upon the ebwa-rtsntioned property for In.
erection purposes.
(We)agree to save,Indeonlly and keep harmless the City of Cuper iro against Ilebllltdee,
ju tgrrreuta,mets al expenses which may In any way accrue against said CityIn consequence SIGNATU OF APPLICANT DAT
of tFa grantin 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