R 5878APPLICATION FOR
REROOF PERMIT
A L-r) l= 2 G eooi�
os(; I,A T I�
CITY OF CUPERTINO
INSPECTION DIVISION
(408) 777 -3228
ADDRESS
PHONE I
ADDRESS
CITY &ZIP ) �O ;66 Y S (I &I osC
PHONE S1147 9SI�
LICENSE
NUMBER
I hereby affirm that I em licensed under provisions of Chapter g (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license Is In full force and
effect. C QI
License CI es - 3 1 Llc. Number I ��]]A• "/(
Date (� _ Contra,W —""L
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to
construct, alter, Improve, demolish, or repair any structure, prior to Its Issuance, also requires the
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Lew (Chapter S (commenclnp with Section 7000) of Division 3 of the
Business and Professions Code) or that he Is exempt therefrom and the basis for the staged
exemption. Any violation of Section 70314 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars (5500)J:
❑ I, as owner of the property, or my employees with wages as their sole compensation, will do
the work, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Profes.
dons Code: The Contractors License Law does not apply to an owner of property who builds or
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
not build or Improve for purpose of eels.).
❑ I, as owner of the property, em exciuelvey contracting with licensed contractors to construct
the project (Sec. 7044, Business and Professions Code: The Contractor's License Law does not
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.
EI I am exempt under Sec. ,B s P. C. for this reason
Owner Date
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 Worker's Compensation,
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
permyl� 10 Issued.
I�x have and will maintain Worker's Compensation Insurance, as required by Section 3700 of
ih a or Code, for the performance of the work for which this permit Is Issued. My Worker's
Compensation Insurance carrier and Policy nu ber are:
t
Carrier 1 � Fu 4, Policy Noo lO6D 0
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed If the permit Is for one hundred dollars ($100) or Ie3e.1
I certify that In the performance of the work for which this permit is Issued, 1 shall not employ
any person In any manner so as to become subject to the Workers' Compensation Laws of Cell.
tennis.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
with such provisions or this permit shell be deemed neaokad,
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 raising to building construction, and
hereby authorize representatives of this city to enter upon the above - mentioned property for Im
spection purposes.
(We) agree to save, Indemnify and keep harmless the City of Cupertino against Ilabllales,
judgments, coats and expenses which may In any way accrue against said Clry In consequence
of the granting of this permit.
9��StNILi�
TEAR OFF INSPECTION:
NUMBER R- 5878
PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1B0 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
RESIDENTIAL K COMMERCIAL - OTHER
YES ❑ If yes a — I undaTtand that Class A
roof assembly is required.
NO ❑ Initial I.C.B.O. #
EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS
TO BE REMOVED X TO BE RETAINED
TYPE OF ROOF
EXISTING
COVERING
BUILT -UP ROOF
❑ o
ASPHALT SHINGLES
Y
/
WOOD SHAKES
/
'
WOOD SHINGLES
❑
OTHER (SPECIFY)
❑
PROPOSED
P A I D
BUILT -UP ROOF
AND 7 Affill
ASPHALT SHINGLES
CITY h❑ Ur cn unJ
WOOD SHAKES
WOOD SHINGLES
❑
OTHER (SPECIFY)
❑
PROVIDE I.C.B.O. REPORT NO.
PROVIDE MFGR. INSTALLATION SPECS.
APPLICATION DATE
VALUATION
PERMIT FEE
o.
Building
7�-9
5 Q 0 0
Seismic
Total s�
PER THORIZATI
DAT E
f-/- -/*/ % : (
yw roots s9an oe mspectea prior to any rooting material being
installeSV If a roof is installed without first obtaining an
inspe on, I agree to remove all new materials for inspection.
App cant understands and will comply with all'non point
source regulations.
All rrr of ncovveeri(q}ps t /e� glass "C" or bette�r.
SIGNATURE OF APPLICANT DATE
INSP. DATE
FINAL:
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
/