R-5446 APPLICATION FOR CITY OF CUPERTINO
NUMBER PERMIT
R— 5446
INSPECTION DIVISION PERMITEXPIRATION
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
6,0 arl1040 RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
�'�rA I/ � VES [I/ Ifyes s Iunderstand that. Class
NAME_ ,OO�i • ��/l roof assembly is required.
jv� NO Initial LC.B.O.q
ADDRESS :Pnt,toa p� EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS 1
CONTRACCIW
NAME (/ �w�� TO BE REMOVED TO BE RETAINED
ADDRESSQ TYPE OF ROOF COVERING
GITY8ZIP A" f Sti SCT a �ISTING
PHONE
E7�� Z— BUILT-UP ROOFLICENIS />_i 6
NUM Eafe" ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES Z Sy
7000)of Division 3 of the Business and Professions Code,and my license Is In lull forte and
affect. I '
i7a! WOOD SHINGLES ❑
Lltensa Class Lic.Number
Date Contractor
ME ITHER(SPECIFY) ❑
0 NER-BUILAL DER DELATION ED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sac.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,alter,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 Is licensed pursuant to the provisions
of the Contractor's License Law(Chapter 9(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
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to /
a civil penalty of not more than five hundred dollars($500).): WOOD SHAKES
E]1,as owner of the property,or my employees with wages as their sole compensation,will do
the work,and the structureContractors
is not Intended or s not for sale(Sec.7044,Business and Proles- !0
Improves
Code:The,an who
License Law ei self appal through
ovine property who rovidebuilds or WOOD SHINGLES
Improves thereon,and who does such workhimselffoil al .It,how his own employees,Improve that
such d within
oneyeare not Intended oro fferedforleer. itl however,them of pros Improvement
Is not bull or
prove for purpose of
ownerbulltlerwill have the burtlen of proving that he tlld OTHER (SPECIFY)
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 Contracloes License Lew 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 contractpgs)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
F7 am exempt under Sec. ,B&P.a for this reason
Owner Date APPLICATION D 1) VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: AUG
❑ have and will maintain a of the
Lab of Consent to self-Insure for Worker's Compensation, BUildin
as provided have
tardy ill main ain a of the Labor Cotle,for the performance of the work lorwhlch ion, ) , ,n,,.
perm11 is issued. C/j
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of Y Uf LUN $ 16rTTJ1(p_,I
the dor Coda,for the performance of the work for which this permit Is Issued.My Workerb ` rIfvo .I.
Compensation Insurance carrier and number are: �1'
oCP)
Carrie PaIIcyN PERMIT AUTHORIZATION DATE
CERTIFI ATE OF EXE TIDN FROM WORKERS'
COMPENSATION INSURANCE N.GI]
(This section need not be completed if the permit Is for one hundred dollars($100)or less.)
I certify that In the performance of the work for which this permit Is Issue Shall not employ
any person in any manner so as to become subject to the Work s'Comp don Laws of call- All roofs shall be nspected 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.
NOT CE TO subacct t.the Worrkerss'Compensetion proviANT: 11,after sions ofethelLaborr me,you musufo thwlithbecome
Comply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. Source regulations. -
I certitythat I have read this application and state that the above Information le correct.I agree
to comply with all city and county ordinances and state laws seating to building construction,and All roof coverings to be s"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for im
herebspection purposes. fill
(We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may in any way accrue against said City in consequence 4,GNATOREOPKPPLICANT DATE
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
OFFICE COPY