R-5219 APPLICATION FOR CITY OF CUPERTINO
NUMB PERMIR R- 5 219
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
•
WITHIN DAYS PERMIT ISSUANCE OR
WI DANSS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
90& ?-7 v`MAJ RESIDENTIAL X COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
�z���^� YES ❑ If yea—assembly
is req that. Clan A
NAME root assembly is required.
NO Initial— LC.B.O.q
ADDRESS Jam( EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS '
CONTRACTOR'S
TO BE REMOVED l TO BE RETAINED
NAME ` �/l✓l is /C.i9 a
ADDRESS 391E y� a s--S / TYPE OF ROOF COVERING
CITY&ZIP N. rzo
EXISTING
PHONE 7z - BUILT-UP ROOFLICENSE
❑
NUMBER 613.,
ASPHALT SHINGLES El
LICENSED CONTRACTORS DECLARATION -
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES RWr
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect' WOOD SHINGLES ❑
Q m 00
ale Contfor License Cla C• 13 • Lic.Nuber
tT OTHER(SPECIFY) �^ ❑
Drac \
OWNER-theConROECLAf TION PROPOSED
hereby affirm that am exempt from the Contractor's or roue Lew for the following reason.
(Sec.construct,
It Business and Professions Code: Any city or county which requires a permit to
construct,alter,Improve,demolish,or repeat any structure,prior to Its issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisionsot
• of the Contractors License Law(Chapter hIsex(commencing with Section]000)of Division 3 of the
Business and violation of Code)or the.he Is exempt applicant
a and the basis for the applicant
1tl ASPHALT SHINGLE.
exemption.Any violation el Section 70315 by any s($5anl for a permit Subjects the eppliran.tp ��
e civil penalty of not more than five hundred dollars(SB00)J: WOOD SHAKES
I,as owner of the property,or my employees with wages as their sole compensation,will do
the work,and the structure Is not intended or offered for sale(Sec.7044,Business and Profes. Q
exons Code: The Contractor's License Lew does not apply to an owner of property who provided
or WOOD SHINGLES /`�. ❑
Improves thereon,and who does such work offered
himself or through ev own employees,Improvement
etl that ,X
such Improvements are not completion,
or owned boli edea.ill however,the en of pr or Improvement
Is sold ntbuild or
year of for purpose of
owner-builder will have the burtlenelprovingthat hedid 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 Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or improves the roan,and who contracts for such projects
with a contractors)licensed pursuant to the Contractors License Law, PROVIDE MFGR.INSTALLATION SPECS.
[:]I am exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
SO I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, � ' BUIId In
as provided for by Section 3700 of the Labor Cotle,for the performance of the work for which this O / 450?
I p , ` r—
Qn—
parmu have and
Foe 13a TO y $eISfT11C .L�
have and will maintain Workers Compensation Insurance,as required by Section 3700 of % {� 444;
,in Labor Cotle,for the performance of the work for which this permit Is Issued.My Worker' Total� Total
1 mea(n}@tion Insurance artier and Policy number are: / ,
carrier``^^+• � /� Policy No,IL�9L• 11303 ZS W-F RMIT AUTHORIZATION DA E
CERTIFICA E OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑ Iv
(This section need net be completed It 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,I shall not employ
any person in any manner so as to become subject to the Workers'Compensation Laws of Cali- All roots shall be inspected prior to any roofing material being
fornia. 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 point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply P Y p
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 ryfc rmGS,t�oDe cl Ss 'C"or better.
hereby authorize representatives of this clay to enter upon the above-menaonetl property for In- , / /7 96
hereby
purposes. l-1�J/
(We)agree to save.Indemnify and keep harmless the City of Cupertino against liabilities,
judgments,seats and expenses which may In any way accrue against seed City In consequence SIGNATURE F APPLICANT DTE
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 ACCESSTO ROOF SHALL BE PROVIDED.FOR INSPECTION
OFFICa-COPY