R-5448 APPLICATION FOR CITY OF CUPERTINO
NUMB PERMIR R- 5448
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-.3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
• 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIA COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
���,� (�� YES L-] If yes—I understand that a Class A
NAMEL�S" Ps J'�l 1 roof assembly is required.
_ NO ❑ Inifil I.C.B.O.k
ADDRESS (0f ���' Qu�o� c>'E - EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S ,_'
NAME O �` TO BE REMOVED TO BE RETAINED
o O �vtC
_ TYPE OF ROOF COVERING
ADDRESS r C' ZZ
clTvsz(l/P '1143 j 5o. f^S4 _ SA,,.1os� EXISTING
PHONE` STC I � S�Q BUILT-UP ROOF
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION ,
1 hereby affirm that I em licensed under provisionsf of Chapter 9(commencing caliSection WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is in full force and -
effect. / WOOD SHINGLES
License Class `" Lic.Number
Yo OTHER (SPECIFY)
Date Cont or -
OWNER-BUIL O PROPOSED ppL
I hereby affirm that I am exempt from the Contractor's cense Le for the following reason. A
(Sec.7031.5,Business and Professions Code: Any city hick requires a permit to
construct.alter,improve,demolish,or repair any structure,prior to its issuance,also requires the BUILT-UP ROOF 2�tEC°D
applicant for such permit to file a Signed statement that he is licensed pursuant to the provisions 'P U f([l7 N
of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 afire
Y
• Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES o ❑
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to /'1' Y
µ1
a civil penalty of not more than live hundred dollars(8500).): WOOD SHAKES CITY VI- GUT(, (IVU
❑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-
sions Code:The Contractors 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.If,however,the building or Improvement - d;.�t��{
is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER (SPECIFY) C
not build or Improve for purpose of sale.).
❑I,as owner of the property,am 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 thereon,and who contracts for such projects
with a contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PER T FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, BU
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is Issued. qr�
1pave and will maintain Worker's Compensation Insurance,as required by Section 3700 of 10 _Z_ �� 7I(� ( S 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: Total
Carrier Nj (^ti�A Policy No. S�2
S - PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O zgru
(This section need not be completed If the permit is for one hundred dollars($100)or lase.)
I certify that In the performance of the we
arwleM4 arms Issued,I shall not employ
any person in any merriest so as to baso subject to ,e wor pensatio La of all. All rod hall be inspected prior to any roofing material being
fornla.f� installed. If a roof is installed without first obtaining an
Date J Zo App1; am _ inspection,I agree to remove all new materials for inspection.
NOTIC O APP ICANT: If,after m ih' ertificate of mmpfor,you should become Applicant understands and will comply with all non dint
subject to aWork rs'Compensation Prov sion of the Labor Co e,you must forthwith comply PP P Y P
with such provisions or this permit shell be dee d revoked. Source regulations.
I certify that l have reed this eppliratlon and state A ova information is correct,l agree
to comply with all city and county ordinances and state laws relating to building construction,and roo c 'ngst be class"C" rbetter.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes.
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities, I O T) 4L
he grating of this perrmitcosts and ses which may in any way accrue against said City
ftjudgments, In consequence TURE AP NT DJTE
• PRE-INSPECTION: PLYWOOD: I -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
OFFICE COPY