R 5109 (2) PERMIT R_ 510 9
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (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
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
E , �O n� YES ❑ roMw undo is req iced. Cass A
NAME lJt '�� root assemdy is required.
��/��
���� �� NO ❑ Initial I.C.B.O.M
ADDRESSS01—e �+C - EXISTING ROOF COVERING
PHONE
^ NUMBER OF EXISTING COVERINGS
CONTFACTORS
r 1b BE REMOVED TO BE RETAINED
y NAME
ADDRESS \ �O G'� „ /-A /J �. TYPE OF ROOF COVERING
CITU 8 ZIP "1 C..{ q���1. EXISTING
PHONE /�` 1 BUILT-UP ROOF ]
LICENSE ASPHALT SHINGLES
NUMBER �/ ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Cotle,and my license is In full force and
effect. WOOD SHINGLES
License Clas Lia Number
Data Coniredor
OTHER(SPECIFYP ❑
ER-BUILDERD LAgcense .^'`/,11 PROPOSED 9flA�
hereby at rm that am exempt from Co e: Any city License Lew which
chthe following reason. " k71.71
(Bec.7031.5,Business and Professions Code: Any city or county which requires e permit to �p
construct,'alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP
applicant for Such permit to file a signed statement that he Is licensed pursuant to the provisions Uf LU��kII _
of the Contractor's License Law(Chapter 9(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 U❑ �'�
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than live hundred dollars($500).): WOOD SHAKES
❑I,as owner of the property,or my employees with wages as their sole compensation,will do ❑
the work,and the structure Is net Intended or offered for sale(Sec.7041,Business and Proles.
alone Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES
improves thereon,and who does such work himself or through his own employees,provided that ❑
such Improvements are not Intended or offered for sale,If,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER (SPECIFY) ❑
not build or Improve for purpose of sale.),
I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7D44,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
E]I am exempt under Sec. ,B 8 P.C.Mr this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration;
❑I have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, BUlldin
irli
pefor by Section 3700 of the Labor Code,for the performance of the work for which this I'(�
permit is ie Issued. �Vl S Sf�lyE
❑1 have and will the performance
Worker's Compensation Insurance,as required by Section 3700 of V
the Labor Code,for ins performance of the work for whish this permit Is Issuetl,My Worker's
Comp en o Inzesur co cerrler/�Ad-�-Policy numb ere: '�J"`'/��I ^ I
f
Carrier C 4 1 Policy No.' v (�2S q
PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed it the permit is Mr one hundred dollars($IDO)or leas.)
I certify that in the performance of the work for which this permit Is Issued.I shat not employ
any portion In any manner so as to become subject to t Work pensation we of C If. A oofs shall b Inspected prior to any roofing material ing
� alled. If a roof is installed without first obtaining an
oald� 10 APPL�CANT If after Applicant inspection,I agree to remove all new materials for inspection.
subject to theWorkers'Compensatlon provisional of the flLabor Code,cate of yoiu mustuf nhwlimccc ply Ae Me pplicant understands and will comply with all non point
with such provisions or this permit shaNbe deemed revoked source regulations.
I certify that I have read this application and state that the above Information is correct.)agree
to comply with all city and county ordinances and state 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-
eppurposes.
(We)
(We)agree to save,Indemnity and keep harmless the City of Cupertino Ci against liabilities,e
judgments,
fthe granting of this permit.ea which may In em war accrue against said City in consequence 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