R-5222 PERMIT R_ 5 2 2 2 .
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
WI180 DANS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS _L n
RESIDENTIAL_ COMMERCIAL OTHER
OWNER'S - HAZARDOUS FIRE AREA
YES ❑ If yes-I understand that a Class A
NAME roof assembly is required.
NO Initial I.C.B.O.q
ADDRESS S -7 -7 �j q EXISTING ROOF COVERING
PHONE y� / ✓-7 S �/ / NUMBER OF EXISTING COVERINGS
CONTRALTO 'S .0A n
NAME—SL �/Cis TO BE REMOVED TO BE RETAINED
ADDRESS r 90 ln, / �-, ,1 v TYPE OF ROOF COVERING
cervazlP ��Ll�l L W
I vii-eye 9 p EXISTING
PHONE B w — e `� �-F �L 0r� A
BUILT-UP ROOF
LICENSE / Clyz
NUMBER ASPHALT SHINGLES),-CUs' O
LICENSED CONTRACTORS DECLARATION
I hereby allirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Cada,and my license is In lull force and TT
effect' WOOD SHINGLES ❑
License Class Uc.Number v
Date s-- u1cf7 Contractor Z..1� OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATIO'I PROPOSED
I hereby affirm that I am exempt from the Contractors License Lew for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,alter,Improve,tlemollsh,or repair any structure,prior to Its Issuance,also requlree th BUILT-UP ROOF ❑
appllcanl for such permit to Its a signed statement that he Is Ilceneed pursuant m the Provisions
of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Divislon 3 of the �=\
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged PHALT SHINGLES ❑
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e civilpenalty of not more leen floe hundred dollars(h wag): � D SHAKES
❑Irks owner structure
I not I tendedmy employeeswithfor
as(Sec.their Bole compensation,will s.
the work,and the Structure Is not emended or offered for sale(Bea es'of Business and Profen- �` l�
star Code:thereon.
Contractor's License Low does not apply to an owner of property who builds or �VpOOD SHINGLES ❑
Improves thereon,antl who does n such workhimselffor or through els own employees,provided that �C
such Improvements are not completion,
or offered for seer.LL however,the bullding pr or Improvement g that he did
not Is sold
or
year of for purpose of steaownerbulltlarwin neve the burden of provingthathetlitl OTHER(SPECIFY) ❑
nal bulttl 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 Contractors 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 contractor(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
1 am exempt under Sec. ,B a P.C.for this reason
Owner Dale APPLICATION DATE VALUATION PERMIT 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 Workers Compensation, 00 Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which tela n (�
permit IS Issued.
Seismic.
❑1 have end will the performance
Worker's Compensation the workfor Insurance,as required by Section 3700rs /
theCo Labor Cade,for the pedormanae of the work for which this permit Is Issued.My Workers
Compensation Insurance terrier elnyp'olicy number are: Total
i Carrier 0� `---0..4 L Policy No. N We-30 1 PERMIT AUTHORIZATION DATE
CERTIFICATE OF XEMP INSURANCE
FROM WORKERS' _
COMPENSATION INSURANCE 100)o
(This section need not be
CERTIFICATE
If the permit is for one hundred dollars($100)or leas.)
1 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 toe 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.
NOT CE TO APPLIANT: It,after of Exemtion
subject t.the Workers'Compensation provisions ofthelLabor Code,cate you musluforthwlilthbecome comply 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 slate 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 coveringst Class Or better.
hereby authorize representatives of this city to enter upon the above-manffoned property for In- n
ape
'Wpurposes. `/.
(Wel puree to save, Intlemnliy and keep harmless the City of Cupertino egalnei liabilities, '7/l
• of the granting of this permsas which may In any way accrue against said City Inconsequence
itSIGNATURE OF4APPLICANT ATE �—
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