R-5525 (2) APPLICATION FOR clTv of cuPERTINo
NUMBERPERMI5525.
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
'
WITHIN 1B0 DAYS OF PERMIT ISSUANCE OR
WI180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
lY fY L� �i RESIDENTIAL COMMERCIAL OTHER
Ow R'S HAZARDOUS FIRE AREA
/ O �/ 440;'f
�0;'f YES ❑ II yeas I assembly
is required. Class A
NAME ,V /�"{��� roof assembly Is requlrlf0.
/0i � fl G����l/� NAIL' Initial- I.C.B.O.a
—, U� �
AODREss EXISTING ROOF COVERING
'PHONE 64 O 72
NUMBER OF.EXISTING COVERINGS
CONTRACTOR'�J'�J��'v// ///�,/ /'�//��/ 4
NAME / G/��� / k 1y01 `�' �/✓../TT,K' TO BE REMOVED 0&1 TO BE RETAINED
ADDRESS f7/ /�7p'��� S-r `a %! /kill TYPE OF COVERING
CITU BZIP J ( //�
7;Z �a-7 C� EXISTING Q
PHONE 7 BUILT-UP ROOF ! fe] l
LICENSE
NUMBER ASPHALT SHINGLES ❑ Q
LICENSED CONTRACTORS DECLARATION 'P
I hereby affirm that I am licensed under provisions of Chapter 9(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 ❑ P �I '
License Class t, Uc.Number A D
�r OTHER(SPECIFY)
Data / / Contractor (//�
OWNER-BUILDER CLARATIO PROPOSED yb �1
I hereby affirm that I am exempt from the Contractor's Licarl Law for the following reason. C�/.7 TF/ryp
(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 uhLU/-
applicant for such permit to fila a signed statement that he is licensed pursuant to the provisions BHT/N
' of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the 0
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(8500).1:
❑I,as owner of the property,or my employees with wages as their sale compensation,will do WOOD SHAKES ❑
the work,and the structure Is not intended or offered for sale(Sec.7044,Business and Profen
slops Coca:The Contractor's Licenser Law does not apply to an owner of property who builds or WOOD SHINGLES pL
Improves thereon,and who does such work himself or through his own employees,provided that ❑ FG /�
such improvements are not Intended or offered for sale.If,however,the building or improvement `Is sold Ithin 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(Sec.7044,Business and Professions Code:The Contractor's 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 contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Data APPLICATION DATE VALUATION PERM T
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
L]I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, L^2���� / / Building
as provided for by Section 3700 of the Labor Coda,for the performance of the work for which this o
permit is Issued. Seismic
I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
the Labor Coda,for the performance of the work for which this permit Is issued.My Worker. Total
-the
Insurance carrier and Policy number are:
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.
(This section need not be completed If the permit is for one hundred coffers(S1 a ess.)
I certify that In the performance of the work for which this permit Is issued,I shell not mploy
any person In any manner so as to become subject to the Workers'Compensation Laws of Cali- All roofs shall&insf ected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date d"1' �� Applicant ��� inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: II,after making Is Certifica of Exemplar,you should become Applicant understands and coil comply subject to the Workers'Compensation provis ons al the Labor Code,you must forthwith comply ply with all non point
with such provisions or this permit shelfbe 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 coverings to be cl better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spection agree
os. ��'�j•�f
•
(We)agreet
e save,Indemnity and keep harmless the City of Cupertino against liabilities,judgments,coatss and expenses which may In any way accrue against said Cityin consequence
of the granting of this permit SI A URE F A LICANT 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