R 5127 (2) PERMIT R_ 512 7
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IFWORK ISNOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
Z 70 Z � L�, Ckpe lh 0 I /
RESIDENTIAL V COMMERCIAL OTHER
OWNER'S J HAZARDOUS FIRE AREA
YES If yes—I underaland that a Class A
NAMES` root assembty Ls required.
�//— NO. ❑ Initial I.C.B.O.#
ADDRESS Z Q1L11 l� � �`�"� EXISTING ROOF COVERING
xr
PHONE "DO- 7Y' Z`-' NUMBER OF EXISTING COVERINGS
CONTRACTOR'S „ �y (�
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS ¢. A/Y `y -E3 U--Q, TYPE OF ROOF COVERING
CITY&ZIP
EXISTING
PHONE BUILT-UP ROOF
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(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 Class Lic.Number
Date contractor OTHER(SPECIFY) Sep ❑
OWNER-BUILDER DECLARATION PROPOSED I `� �gys
1 hereby affirm that I am exempt from the Contractors License Law for the following reason.
(Sec.7031.5,Business end Professions Code: Any city or county which requires a permit to / _
construct,alcor,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF C,,❑
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions lV
of the Contractors License Law(Chapter a(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 sale(Sec.7044,Business and Proles.
alone Code:TheContractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑ `^ In,
Improves thereon.n,and who does ed or offered for
Salo.or rt,however,
ove s own employees,r Improvement
such Improvementsnd not does sucororkhi fors ale.if,ugh his own
employe s,improvement l WSN
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.).
❑1,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(See,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 conhactor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
I am a empt der Sec. ,B a P.C.for this reason
in
Owner Date
WORKER'S COMPEAT N DEARATION R
APPLICATION DATE VALUATION P MIT FEE
f CL
I hereby o ire under penalty of perjury one o e following declaration:
❑1 have and will maintain a of the
of ode,for to Performa for Worker's Compensation, O M'^ BD
as mit Is issued.
s for by Section 3700 0l the labor Cove,for the performance of the work for which this (•fL/ !/ /K_/ lY V
permit le ive and SeIS
s ❑ neve entl will the performance
Worker's Compensation Insurance,as required is i su Section 3700 s
the Labor Cotle,for the pedormand of the work for welch this permit is issued.My Workers C/V
Compensation Insurance carrier entl Policy number are
Q TOtflI
Carrier Policy No. P RMITAUTHORI AT
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed If the permit Is for one hundred dollars($100) r less.)
I certify that in the pedormence of the work for which this permit Is Issued,I shell not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Cell- All roof.^.shall be inspected prio o any roofing MrAterial being
forma. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
subject to the WoICE TO rkers'APPLICANT.
f,after nsation provisions of the this Certificate C ,yyExemption,st fyou oinwliin 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 state that the above Information is correct.I agree
to comply with all city and county ordinances and stare laws relating to building construction,and All 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 tos save,indemnity eesw end keep harmless the City ai Cupertino agalnat liabilities,
ofjudgments,the gran coats and permit. a which may In any way accrue against said Clty in consequence
of granting puma permit. SIGNATURE OF APPLICANTDATE
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 COPV