R-5388 (2) PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 5388
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1110 DAYS OF PERMIT ISSUANCE OR
1 100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNERS HAZARDOUS FIRE AREA
.// . YES ❑ If yes-I understand that a Class A
NAME cot assembly is required.
NO Initial I.C.B.O.#
ADDRESSQom/ /p� EXISTING ROOF COVERING
PHONE 0-5 Z —`-1 1 J NUMBER OF EXISTING COVERINGS I
CONTRAC S ��/f�y�/
NAME .moi 1!?: - - TO BE REMOVED f TO BE RETAINED
ADDRESS 5 a TYPE OF ROOF COVERING
clry a zIP oi_ , �A q 430
f EXISTING
PHONE "t 1- 4`33 -63 73 BUILT-UP ROOF ❑
LICENSE NUMBER 4 �—� O a ASPHALT SHINGLES El
LICENSED CONTRACTORS DECLARATION '
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 01 the Business and Professions Code,and my license Is In full torte and
effect' WOOD SHINGLES
License Class Lic.Number a O ❑
ld��Q
Data Contractor
OTHER(SPECIFY) ❑
OWNER.BUII ATON PROPOSED s�s
I hereby affirm that I am exempt from the Contractor's License Law for the Ireason. P A
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to W
construct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions o
of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the y
• Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES`x/r T REC _
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to y Ln�/%�
a civil penalty of not more than five hundred dollars($500).): WOOD SHAKES / Ur �../
01,as owner of the property,or my employees with wages as their sole compensation,will do U9 ;fr rN
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profos-
slons Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑
improves thereon,and who doessuchwork himself or through ev own employees,improvement provided that
such Improvements are not Intended the
offered for leer.ill however,the building or improvement pQ
ntbuilsold d or
prove for purpose
sale.).Owner-buileerwlll have the bumenof proving that he tlltl OTHER(SPECIFY) ❑ 0J
not build or improve for purpose of ealaJ.
❑I,as Owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.704,Business and Professions Coda: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.
❑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:
-11 have and will maintain a Certificate of Consent to sell-Insure for Workers Compensation, /// � Buildin�
as provided for by Section 3700 0l the Labor Code,for the performance of the work for which this / �/ tl
perms(((hs.s vsued. 1 / [ r(S(� Seismic
Y�have end will maintain Worker's Compensation Insurance,as required by Section 3700 of
Ih abor Cotle,for the performance of the work for which this permit Is issued.My Worker's
C mpensation Insur nca�arrier and Polity number are: Total
Carrier 's «/ k' Policy N6S_7L:D_//25 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
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 an anner o as to become subject to the rd+ rs'Comp satlon Laws of Cali- All roofs shall be inspected prior to any roofing material be ng
Iernl°. !U installed. If a roof is installed without first obtaining an
Date a Applicant '-�- inspection,I agree to remove all new materials for inspection.
become
subject I.i.the Dw rk�aCc mpeIf.
nsatl n provisionthis
s ofthelloillife of Laborr Code,Exemption.
must forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shall ba 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
hereby `y'y
y authorize representatives of this city to enter upon the above-mentioned property for In- co tlrl be cies "C"or better.
spection purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may in any way accrue against said City In consequence
'
at the granting of this permit. SIGNATURE OFAPPLICANT 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