R-5520 (2) APPLICATION FOR CITY OF CUPERTINO
NUMBI ERR– 55 2
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
M180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
t/ S. e , �/' VES ❑ Ityes s Imbly istandthat. ClassA
NAME �T (- !' G1Ci G/C roof assembly Is required.
ADDRESS r 5_,3,9 &zv 6, Vy C EXISTING ROOF COVERING
PHONE — /� / NUMBER OF EXISTING COVERINGS
CONTRACTOR'S -
NAME �
TO BE REMOVED TO BE RETAINED
.� ���C� �r7y�
ADDRESS 30�3 . 2G� TYPE OF ROOF COVERING
CITYa zlP [ ('J / FJ EXISTING
PHONE BUILT-UP ROOF
LICENSE /
NUMBER 3 ASPHALT SHINGLES
C9
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 0(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and
effect.
J?3 WOOD SHINGLES /
Date
License Close UContractor '—c.Number (.�
�j� OTHER(SPECIFY) ❑
Dat
OWNER-BUILDER DECLARATION PROPOSED
1 hereby ffirm that em exempt from the Contractors License Lew for the IOIIowInB reason.
(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 o its Issuance,also requires the BUILT-UP ROO� ;,I Q
applicant for such permlt to file a signed statement that he Is licensed pursuant to the provisions P
of the Contractor's License Lew(Chapter 0(commencing with Section 7000)of ovlslon 3 of the
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES 4 REC ❑
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to 1 1
a civil penalty of not more than five hundred dollars($500).): WOOD SHAI1 E]❑I,as owner of the property,or my employees with wages as their sole compensation,will do 1(�J
Slone Codhe work,e;The Contractors Licensd the structure Is not e Lew doeded or s no applred for y to an owner of property who build,Business and s or r V v' '1 r1 '
Improves thereon,and who does such work himself or through his own employees,provided that WOOD SH%g4ES ❑
such Improvements are not Intended or offered for sale.It,however,the bulli ing 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 eels.).
C]1,as owner of the property,em 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 ouch projects
with a contractor(s)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
0I am exempt under Sec. .B a P.C.far this reason
Owner Data 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 Worker's Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this i/ ,,.. // �x O
permit is issued. / 1�- (/ 75o "— Seismic
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of [/
the Labor Code,for the performance of the work for which this permit Is issued.My Workers
Compensation In anal and Policy number are: Total
Carrier % 7 ZWAMPolicy No.2 95-- 131 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O �s ✓, n`y
(This section need not be completed If the permit is for one hundred dollars fill 00)or less.)
I certify that In the performance of the work for which this permit Is Issued, shell not employ
any person In any manner so as to become Subject to the Workers'Compensation Laws of Cali- All roofs shall be inspected prior to any roofing material being
forums. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
subjectI.Etn Workers'Compensation O APPLICANT: provisionthis
s of the Labor Laborr Code,yocater of u must forthwith le Applicant understands and will comply with all non point
with Such provlsons or this permit shall deemed revoked. y comply source regulations. -
I certify that I have read this applicetlon 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 AI r of coverings to be cl s"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, 7 y
judgments,costa and expenses which may In any way accrue against said City In consequence
of me granting of ora permit. ATURE OF APPLICANT DAT
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