R 5435A
OFFICE COPY
PERMIT
NUMBER R 5 4 3 5
APPLICATION FOR CITY OF CUPERTINO
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 777-3228 PERMIT EXPIRES IF ORK IS NOT STARTED
PERMIT
WITHIN 180 DAYS OF ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION,
BUI'/L-/D�ING/ADDRESS
//7�y1-
- q`o'7 � (37
•
RESIDENTIAL COMMERCIAL OTHER
OWNER'S -
HAZARDOUS FIRE AREA
YES ❑ If yes- I understand that a Class A
NAMEQ
roof assembly is required.
NO Initial I.C.B.O. #
j �/
4,0!7
EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS
TO BE REMOVED __ TO 6E RETAINED
ADDRESS /�7 ,0 TQGGr1i
�/7 i
PHONE O 117A . 0 ��C1
CONTRI /] /� /�
- !/ n-..OJJ ,� n
r.rM. UI �/ • w. / , Par
NAME—S..r/ULV �L///l. A.iA LL(� /L -CJ CJTI,W
TYPE OF ROOF COVERING
EXISTING
ADDRESSrS,�'�� /� J
CITY 8 ZIP '7 ( �! ���
// pp �j//_ �7, // /
110�,
,3&9 /`7`7b
PHONE _110,?-,3&9-
❑
BUILT-UP ROOFLICENSE
p'-
NUMBER fo9l44;ta
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed untler provisions of Chapter 8 (Commencing with Section
WOOD SHAKES
7000) of Division 3 of the Business and Professions Code, and my license Is In full force and
effect.
WOOD SHINGLES ❑
License Clas Lic. Number
, gA7i III
OTHER (SPECIFY) ❑
Dale ContraetorJn
OWNER -BUILDER DECLARATION I
I hereby affirm that I am exempt from the Contractors License Law for the following reason.
pgOPOSED
(Sec. 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 ❑
eppllcant for such permit to file a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law (Chapter 8 (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).):
C] 1, 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 offered for Bele (Sec. 7044, Business and Profes.
sions Code: The Contractor's License Lew does not apply to an owner of property who builds or
Improves thereon, does
'WOOD SHINGLES ❑
and who 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
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.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct
�{..
the project (Sac. 7044, Business and Professions Code: The Contractor's License Law does not
PROVIDE I.C.B.O. REPORT NO. 5S
apply to an owner of property who builds or Improves thereon, and who contracts for such projects
with a contractogs) licensed pursuant to the Contractor's License Law,
❑ I am exempt under Sec. ,B 6 P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner Date
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION
PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration;
❑ 1 have and will maintain a Certificate of Consent to self -insure for Worker's Compensation,
\_
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
is issued.
gT q I ®
II� P4
C;0
atlqK 1
BUlldln g
per
have and will maintain WorkeYa Compensation Insurance, as required by Section 3700 of
ih Labor Code, for the of the work for this Is Issued.
Seismic
performance which permit My Worker's
Ccmpen6n sur nc0 ca ierand Pol y number are: /��� ��
carder \J Poncy N
`W 12 ANSn e
,YII'��
Total
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.]
V Cn l IVU
(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 Issued, I shall not employ
All roofs shall be inspected prior to any roofing materia ing
any pereon any manna o as to become su d to the Workers' Compensation Laws of Cell-
f°`n13]
installed. If a roof is installed without first obtaining an
Data 7 Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE
subject to the Workera' Compef, aher nsation provisions Ce fi bor°Oode yolu must forthwshould
ith comply
Applicant understands and will comply with all non point
with such provisions or this permit shafte 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 stele laws relating to building construction, and
roof coverings to be class "C"or better.
hereby authorize representatives of this City to enter upon the above-mentioned property for In.
spection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities,
judgments, costs antl expenses which may In any way accrue against said City In consequence
of the granting of this permit
A E APPL CANT DATE
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