R 5026 (2) APPLICATION FOR CITY OF CUPERTINO NUMBER R- 5026 _
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN PERMIT ISSUANCE OR
I 1 DANSS FROM
LAST CALLED INSPECTION.
BUILDING ADDRESS
/ 44 -,
& aeit /" RESIDENTIAL ±!��CO
MMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA�� VES ❑ If yes—I understand that a Class A
NAME 7'+'�L/Y /I NO roof assembly is required.
lnitial I.C.B.O.H
ADDRESS'/O!/I �w�d 42NO
EXISTING ROOF COVERING
PHONE
Z.7�'- Zp/�7 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S J
NAME �Q` E6 �0'C��✓�1 TO 8E REMOVED TO BE RETAINED
ADDRESS /0 , b41 /- / _ /_ _ 3 Q7 p 4o TYPE OF ROOF COVERING
CITYB ZIP p1S 4'1C/7 "Z+r�i'�
1 EXISTING
PHONE 7y9�`f BUILT-UP ROOFLICENSNUMBER
/ 1, 2 ASPHALT SHINGLES ❑�
NUMBER 'rv� 4�7
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter B(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business end Professions Cotle,and my license le In full force end
effect. WOOD SHINGLES ! '
I^ ^
x!_397
License Class Llc.Number
Date g 94 Contractor St 1S7& Zima4S' OTHER(SPECIFY Ura 1 �
OWNER-BUILDER DEC TION Vr
hereby affirm that I am exempt from the Contractor's Ic se Lew for the following reason, PROPOSED 6
(Sec.7031.5,Business and Profession&Code: Any clty It which requires a permit to
conslruc6 alter,Improve,controller.or repair any structure,Frio s)&suance,also requires the BUILT-UP ROOF Q'
eppllcent for such permit to Ills a signed statement that he iss4�IEe Suent to the provisions
• of the Contractors License Lew(Chapter a(commenclrgp141th o 000)of Division 3 of the
Business and Professions Code)or that he Is axe Ihheref d the basis for the alleged ASPHALT SHINGLES ❑
exemption.Any violation of Section 7037.5 by any p ntl -
11 'It the applicant to
e civil penalty of not more than five hundred tloi m($50
❑I,asowneroftheproperty,ormyemp!t>{eeswith as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure le not Intendetl or offered Is(Sec.7044,Business and Proles.
alone Code:The Contractor's License a no y to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such h mea through his own employees.Provided that ❑ C�
such Improvements are not Intended or o pa la.If.however,the building or Improvement ,�,( r7
Is sold within one year of completion,the n der will have the burden of proving that he did OTHER(SPECIFY) W G
not build or Improve for purpose of sale.). /—
❑1,as owner of the property,am exclusively contracting with licensed contractors to construe
the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or improves thereon,and who contracts for such projects
with a contractor($)licensed pursuant to the Contractors License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec, ,B$P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to selbinsure for Worker's Compensation, Building
G
as provided for by Section 3700 of the Labor Code,for the performance of the work for which thi$ �p g
permit Is leaned. —1"I 17, 10 f/ Seismic
1 have and
will maintainperformance
Workers f the work
for Insurance,as required by Section 3700 0l
r t L bor Cotle,for the performance of the work for which thl&permit le leeuetl.My Workers
ompeneatlon Insurance terrier and Policy number are. Total
Carrier � % ���� Policy Nod /' 4171-94 PERMIT AUTHORIZATION
+ - CERTIFICATE OF EXEMPTION FROM WORKERS'
t COMPENSATION INSURANCE N.C.]
(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 shall not employ
any person In any manner so as to become subject to the Workers'Compensation Laws Cal- All roots shall bE51nspected prior to any roofing material being
forma. e7—7 installed. If a roof is installed without first obtaining an
Date /�� Appllcan! inspection,I agree to remove all new materials for inspection.
subject thICE eOWorkeres'Compefneetler inon provisions of theLaborCode,Exemption,
must forthwou ith 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 State laws relating to building construction,and All roof coverings to be class"C" rbetter.
hereby authorize representatives of this city to enter upon the above-mendoned property for In-
spectlon purposes.
(We)agree to save,Indemnify and keep harmless the City al Cupertino against Ilebllitlee,
jud menta.cost&entl expenses which may In any way accrue against said City In consequence
of tRe granting of thio 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