R 5755 (2) NUMB
APPLICATION FOR CITY OF CUPERTINO
ER R- 5755
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
' 180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
v
RESIDENTIAL COMMERCIAL OTHER
w R's n n HAZARDOUS FIRE AREA
NAME �• /T S• OP l YES � If yes—I understand that a Class A
roof assernbly is required.
NO ❑ Initial I.C.B.O.It—
el�fS� EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
�
NAME lZ�ri/y P� /I �/� ( OiL TO BE REMOVED TO BE RETAINED
ADDRESSrDDy ��, TYPE OF ROOF COVERING
CITYBZIP- /r 7
/ry6Af` e 54?-ewo CA- 9-830 EXISTING
PHONE BUILT-UP ROOF ❑
NUMBER C'39' 6 7 2,92 ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION -
I hereby affirm that I am 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 full force and
effect.
Z o 2 WOOD SHINGLES
License Class. C 3 / uc.Number
Date 7 Contractor
e99NP2 OTHER(SPECIFY) A
OWNER-BUILDER License
PROPOSED
1 hereby affirm Bu rhes am exempt from the Contractor's city or roue Lew for the following reason.
(Sec.7031 It .Improve and Professions rep Code: Any city all county which requires a permit to
conctant for such
tlemoka signed statement
eny menthatstructure,prior lolls issuance,rsuant to the
the BUILT-UP ROOF ❑
of the o for each p icon a flaw a signed statement that he Is Iloeosetl 7000)of to the pro of the
of the Contractors License Lew(Chapter B(commencing with Section 7000)of far the 3 of the
Busine. exempea and violation Of Code)or that he Is exempt therefrom and the brats loll she slanged rA$PF{ACT SHINGLES
exemption.pen.Anyf violation more
of healon hundred
by any epN 500 i for permit subjects the applicant t0
e civil penalty of not more then flue huntlred dollars($800).): ❑
r]1,as owner of the property,or my employees with wages as their sole compensation,will do Wd ryly0 y
O 7Gfn�II[p`{ry(E$
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business
and Profos- UL
alone Code:The Contractor's License Lew does not apply to an owner of property who builds or WOO SHINGLES ❑
Improves thereon,and who does such work himself or through has Own employees,provided that
such Improvements are not Intended or offered for sale.If,however,the building or Improvement (:I Y urOLZ,l7C[I}},1yyyLIFY) ❑
Is sold within one year of completion,the owner-0uloar will have the burden of proving that he dad II FF11 tt HH lJYt(1
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 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(a)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
EJI am exempt under Sec. ,B S 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:
❑I have and will maintain a Certificate of Consent to sell-Insure for Workers Compensation, qy BUIlding�
as provldedfor by Section 3700 of the Labor Code,for the performance of the work for which this /�� � r% O
permit Is Issued. / 1/ 0 a Seismic
❑ have and will the performance
Workers Compensation which this as requiredbySection 370001 ( /
the Labor have
for the performance o/the work for which this permit Is d by S.My Workers Seismic
Compensation Ineuron`fe—sealer V Policy nu ber are: Total
Carrier � `� T GN� Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0 �z
(This section need not be completed If the permit Is for one hundred dollars($100)or leas.) �y
I certify that In the performance of the work for which this permit Is issued,I shell not emotoy 1 1
any person In any manner so as to become subject to the Workers'Compensation Laws Of pall- All roof all be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE APPLICANTbecome
subject to theOWorkers'Compefnsation provisions of tthlelcate Labor Code,of you must fo thwlith comply Applicant understands and will comply with all non point
with such provisions or this permit shaIPbe doomed revoked, source regulations.
I certify that I have read this application and state that the above Information Is correct.I agree
Q
to comply with all city and county ordinances and state laws relating to building construction,and All roof coverings to be class.6 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 Ilabllltiee,
judgments.costa and expenses which may In any way accrue against said City In consequence
at the granting of this permit. SIGNATURE OF APPLICANT 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