R-5782 PERMIT R- rJ 7 8 2 .
APPLICATION FOR CITY of CUPERTINO NUMBER -
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (a08)7n-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 190 DAYS OF PERMIT ISSUANCE OR
BUILDING ADORES 190 DAYS FROM LAST CALLED INSPECTION.
I �
RESIDENTIAL--K—COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
n VES ❑ If yes—I understand that a Class A
NAME - roof assembly is required.
NO ❑ Initial I.C.B.O.tl
EXISTING ROOF COVERING
ADDRESS ,7! -
7 NUMBER OF EXISTING COVERINGS
'PHONE -
CONTRACT /
NAME
70 BE REMOVED TO BE RETAINED
' � A-2.. -
ADDRESS /'� �l - TYPE OF ROOF COVERING
CITY 8 ZIP (•�M
3 6 EXISTING
PHON _ BUILT-UP ROOF -
NUMBEa Z'1 0 0ASPHALT SHINGLES ❑
UCENSED CONTRACTORS DECLARATION
I hereby affirm Mat I am licensed under provislons of Chapter 9(cnnmhend wish Section WOOD SHAKES ❑
7000)of Dviskn 3 of the Business and Professions Code,and my license le In f force a
.Nett.
O OOD SHINGLES ❑
License Cleve � Lk.Number
Dae Cammdor R(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I Am exempt from the Courtrai License Law for the following reason.
(Sec.7031.5,Business and Professore Code: Any clay or county which requires a permit,o
construct,alter,Improve,compiler,or repair any structure,pror to Its laeumce,also requires the BUILT-UP F yAL ��CJ
applicant for such permit to file a signed statement Chet he Is Ilcen.ed pursuant to the provisl
of the Contractors License Law(Chapter 9(commencing with Section 7000)of Divls10 o e 1—I
Business and Professions Code)or Met he Is exempt therefrom and Me basis forth ad S LT I GLES ❑
exemption.Any violation of Sectio,,7031.5byatry applicant for a permit subjecta,hea to
a dNl penalty of not more than five hundred dollars
C-]1,as owmr of Me property,or my employees with papas as their sole co Femme - no � Q�H S ❑
the worhek,and the s,rvdura Is hot Intended or offered for sale(Sec.70",Buelmse a s-SE y
done Coda:TContractors Liconw Law doss mt appy to an owner of property who ds W JL WOO SH ES ❑
Improves thereon,and who does a work him m or through his own employee.,or that
each Improvements Improvements are not Intended or offered for sale.If,howareq the building or Impr ant
is sold wlMln we year of completion,Me owner-builder will have the burden of proNng M he did OTHER ( E FY) ❑
not build or Improve for purpose of si e.).
❑1,as owner of the property,am"elusively convect)ng with licensed!con tractors tot
Me pmlecl(Sm.70",Business and Profen suns Code:The Contractors License taw does hot PROVIDE I.C. .0.REPORT NO.
appy to an owner of property who Wide or Improves thereon,and wro contracts for such projects
with awn,rector(e)licensed pursuant to the Contractors License Law. PROVIDE MFG INSTALLATION SPECS.
L]I am exempt under Sac. ,B&P.C.for Mie mason
Owner
WORKER'S COMPENSATION DECLARATION APPLICATION DATE ALUATION PERMIT FEE
I hereby affirm under penalty of perjury we of Me fallowing declaration:
❑I have and will meinteln a Certificate of Consent to sell-Insure for Workers Comperse on, O`O Building/
ass pmvke!lar by Section 3700 of the Labor Code,for the performance of the work for which Mle /
per Islseued. 9 .�`/Z` `j�j <S Seismic �O
have aro will maintain Worker's Compensation Insurance,as required by Section 3700 of
Labor Code,for the performance of the work for which this permit Is Isaued.My Workers
1b�,jneu— �{c/�j,�ar and Potky number are: Total � ��
C.der 'ui�� Poucy N6����/2 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ
(Title section rued not be competed n Me permit is for am hundred!docars(5100)or lose.)
I tartly that In the perfomnance of Me work for which this permit is issued,I shell not employ
any person M any manner so as to become subject to the workers'CernpmeatIm Laws of Call- All roofs shall be inspected prior to any r)offN material being
lornis. - installed. If a roof is installed without fir obtaining an
Da,a Ipant - inspection,I agree to remove all new materials IRr inspection.
subject,o the WTO or ar%Oo Ince on prrovliaons of the Code,you you.ndnld become Applicant understands and will comply with a non point
pe p you moat lorthwlth comply
with such provislone or this perm,shell W deemed raoketl. SOUfCO regulations. -
I cxi Mat I have read this eppficatkn and slate Mat Mar above Information Is coma(.'.I agree
to campy MM at city and county ordinance.and state laws ralating to Wlicing conathption,and All roof coverings to be class"C"or better.
hereby autthoriza representatives of this dry to enter upon the above-menikned property for In- '
spxtion purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
oldUhe er-Wgrancoo md this permit.eee.which may,In arty way acaua against saki Gry In corxsequerhte SIGNATURE OPPLICANT ATE-
. 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