R-5523 (2) APPLICATION FOR CITY OF CUPERTINO
NUMBER PERMIT
R- 5523
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.
BUILDINGADDRESS
'� COM��
✓" �4-(J J� (�� RESIDENTIAL MERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ 11 yes—I understand that tlClass A
NAME of assembly is required.
NO Inil LC.B.O.k
ADDRESS C2 (�J0 y�/Q EXISTING ROOF COVERING
PHONE ^ d I NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S
r�,�/�CS-�T91� TO BE REMOVED / TO BE RETAINED
NAME
ADDRESS // ' /lam 'TYPE OF ROOF COVERING
CITY&ZIP /�� R�
,rT EXISTING
PHONE• � r:/ � 17 _ BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Divislon�e Business and Professions Code,and my license Is in full force and ry / g
effect. P
�riOOD SHINGLES
License C Uc.Number AUG r
Date 1�Contracto OTHER(SPECIFY) AUG
OWNER-BUILDER DECLARA PROPOSED1,WU
I hereby affirm that I am exempt from the Convector's Li se Law for the following reason. CITY' r,L UrZt'-
(Sec.7031.5,Business and Professions'Code: Any city or county which requires a permit to V
construct,alter,improva,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 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).): WOOD SHAKES (1d l/�//�•'1s�C S
❑I,as owner of the property,or my employees with wages as their sole compensation,will do `ALT
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes-
sions Cade: The Contractor's License Law does not apply to an owner of property who builds or ❑ '�'
Improves thereon,and who does such work himself or through his own employees,provided that WOOD SHINGLES
such improvements are not intended or offered for solo.It,however,the building or Improvement
Is sold within one year of completion,the owner-bullder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑1,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 Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&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: /
❑1 have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this �O
permit is have
anissued. D J Seismic
❑1 have an will m 'peln Workers Compensation Insurance,as required by Section 3700 of O'
the Labor ll ped merry P the work for which this permit Issued.My Workers Total
Compensetl Insur ce c�Oler d P icy number are: I
Carrier 0 PolicyNo;l?a PERMIT AUTHORIZATION DATE
CE RTI FICATE OF 16F&PTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
This section need not be completed If the permit Is for one hundred dollars($100)or lass.) s r
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 become subject to the Workers'Compensation Laws of Cell. All roof^sh e' spected prior to any roofing material being
fornia. installed. If krroof is installed without first obtaining an
Data Applicant In on, gree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become A IicaB derstands and will Comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP P y P
with such provisions or this permit shalf 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 consiructloq an All r0 coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property br In
apache)purposes. n�
(We)agree to save,indemnity and keep harmless the Clry of Cupertino against liabilities. /GZZ
of the grlantingsts and of this perrmiL es which may In any way accrue against said City in consequence SIGNATU PPLI(i 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