R-5576 (2) PERMIT R_ 5576
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOFPERMIT (408)777-.3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN DAYS PERMIT ISSUANCE OR
WI DANSS FROM LAST CALLED INSPECTION.
BUILDIINNG ADDRESS ,1r ( �%/� V� / A �//
zJ V �O� 1'�,` I I k 2jr, `/'-1/ RESIDENTIAL - COMMERCIAL OTHER
OWNER'S�n/ HAZARDOUS FIRE AREA
NAME 1 �� 1 '>` 1 �� 1 1V, 1 YES If yes—Imbly is requirend d. Class
—/roof assembly is required.
p s NO 2 Initial I.C.B.O.n
�6 = UFiL + ZS�o 7 Fj C(•eek /g EXISTING ROOF COVERING
ADDRES 8e5-- 2140
Q\
PHONE 8SJ — / O NUMBER OF EXISTING COVEJNJGS
CONTRACTOR'S V//
NAME TO BE REMOVED TO BE RETAINED
ADDRES (,' 1YPE OF ROOF COVERING .
CITY A 71 �, 5J / (1 Z
p EXISTING
• PHON(4O1J) -/ 71 —1 71 BUILT-UP ROOF El
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES ❑
]000)of Division 3 of the Business and Professions Code,and my license is in full force and
effect.
//�� ' WOOD SHINGLES /
License Clas5��31 i C-��l Lia Number��Z D� v Q - O
^� s OTHER(SPECIFY)
Date�-3-5 I-BUILDERDEC'sLice se PROPOSED /
hereby affirm that am exempt from the Contractor's License Law for the requires
ng reason. !�
(Sec.]0315,Business and Professions Code: Any city or county which requires e permit to
construct,alter,improve,to file asiorrepair any structure,prior licen Its Issuance,also requires the BUILT-UP ROOF A
applicant for each permit to file a signed r 9(co statement that g is licensed pursuant of to the provisions
' o10 .
f the Contractor's License Lew(Chapter B(commencing with Section]000)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 than
fin hundred
by any applicant for a permit Subjects the applicant to Q
e evil,analty s owe not more than property,or my employees
yeesdollars(h wag I: WOOD SHAKES (i/ If��II XP�I �/p
❑Las owner structure
Inoi tended oyaeeredfwages as(Sec. reels compensation,sand
Profes-
sions
s- /)' y-,y [/
the work,and the structure Is not intended ores not for sale(Sec.7044,Business and Prates-
lds or
improvsth:The Contractor's License Lewtliself or
yto an ghhis own employees,who rovidethat WOOD SHINGLES Ur�hrlAl
improves o ereen,and who does nsuch work himself or.If,how his own employees,provided that ❑ NU
such Improvements are not completion,
or ownetl for sale.I(however,burden
en of pr or Improvement
ntbuilsold d or
prove for purpose
stheownerbulltlerwill have the burdenof proving that he did OTHER(SPECIFY) ❑'
net build or Improve ler 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 properly who builds or Improves thereon,and who contracts for such projects
with a contractor(s)licensee 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, BUI Idln�
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of ��///� n/ Seismic ,
the Lab Code,for the performance of the work for which this permit Is issuatl.My Workers ��3 1 1 V Total
Compe ation In an a carre it P Ilcy nun r are:
Carrie IL PolicyNo. 2 $� PERMIT AUTHORIZATION DATE
CER IFICATE OF EXEMPT N FROM WORKERS'
COMPENSATION SURANCE N.C.O
(This section need not be completed if the permit Is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this permit Is Issued,I$hall 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
fornia. installed. If a roof is installed without first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
NOTICE a APPLICANT.s'Compensation
eller making provis inls f the
of ode,you mion ust forthwith comply Applicant under and will comply with all non point
become
subject to the Workers'Com If.after
revisions of the Labor Code, y
with such provisions or this permit shall be deemed revoked. acef regulatio S.
certify that have read this application and state that the above information building
isnscorrect.ioagree
m comply with e11 city and county ordinances and state Taws relating inf bathing construction,and COVerin t0 b ass"C" better.
hereby authorize representatives of this city to enter upon the above-mantioned property for in-
spection
mspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,
of the gr�antingsts and of this permit. SIGNATURE
which may in any way accrue against said City in consequence SIGNA RE OF APPLICANT DITE
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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY