R 5840 a
PERMIT R_ 5840
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
130 DAYS FROM LAST CALLED INSPECTION.
�
BUILDING
ADDRESS
i� 37
� / t%4l (!
RESIDENTIAL—_Z(_COMMERCIAL OTHER
OWNER'S a �n HAZARDOUS FIRE AREA
NAME /�--- �"w T YES ❑ It yes—1 understand that a ClawA
roof assembly is required.
NO ❑ Initial I.C.B.O.k
ADDRESS ��� EXISTING ROOF COVERING
7
PHONE ( NUMBER OF EXISTING COVERINGS
CONTRACT / ///J,,,, // TO BE REMOVED—TO BE RETAINED
NAME S ( Y_Q TT/ S /L-6/�Ci1r—'J '
ADDRESS •/�O QaX ___ /__ ' � - TYPE OF ROOF COVERING
CIN&ZIP—
EXISTING
Tx (�( ti_
PHONE BUILT-UP ROOF ❑
CENSE
NUMBER p ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
hereby affirm that I am licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license le In full force antl
effect. ,73�/ _�G WOOD SHINGLES - ❑
License Cleve Lic.Number
Date Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby allirm that I am exempt from the Contractor's License Lew for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,offer,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he le licensed pursuant to the provisions
of the Contractor's License Law tChapter B(commencing with Section 7000)of Division 3 of the
• Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES rS�XI
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than live hundred dollars($500).):
01,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES
the work,and the structure Is not Intended or allered for sale Sec.7044,Business and Profes. sf
Bions Code: 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 ANsr�
such Improvements are not Intended or offered for sale.If,however,the building or Improvement p
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.(, d
01,as owner of the property.em exclusively contracting with licensed contractors to construct 1,t Ittx.1
the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NQ(I
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.
01 am exempt under Sec. ,B 8 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:
01 have and will maintain a Certificate of Consent to eelbinsure for Workers Compensation, Building r IT
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this _
permit is Issued. / O
O l have and will maintain Worker's Compensation Insurance,as required by Section 3700 of W^� � Seismic
�r('' Q 0
the Labor Code,for the performance of the work for which this permit is Issued.My Worker's d Total /1 r
Compo/��y°e���on Insurance rrler and P nu barer
cerrlAre/n'1G�/A -11 � ey�gayNp.�/ h PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not bs completed If the permit Is for one hundred dollars($100)or less.) �C VI -77
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 became 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
Date Applicant inspection,I agree to remove all new materials for inspection.
EkCeeiimaking
Certificate of
Exemption,
uushould
sublet toh Worea' oompneon provisions of the Labor Code,you mstforthwlhcomply Applicant understands and will comply with all non point
with such provisions or this permit shall be 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 cove 'ngs to be class'8 Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In. p,
6ppurposes.
(We) 4 , !0'
(We)agree to save,Indemnify and keep harmless the City of Cupertino against Ilebllltlee,
judgments,coats and expenses which'may In any way accrue against said Clty In coneaquence s,
of the granting 01 this 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 j
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY