R-5307r*
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OFFICE COPY
NUMBER R- 530 7
APPLICATION FOR CITY OF CUPERTINO
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
OVINER'S
HAZARDOUS FIRE AREA
ClassA
YES ❑mbly
NAME_ `tSCyY�
s�requi eta
NO ❑ Iniga I.C.B.O. R
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ADDRESS y (�-�Fit'' ??✓611' K �jj�n -��
EXISTING ROOF COVERING
Y
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PHONE off/
NUMBER OF EXISTING COVERINGS
/y'
CONTRACTpR'S
NAME
TO BE REMOVED t"' TO BE RETAINED /��
ADDRESS -, ...
,: �0
TYPE OF ROOF COVERING
CITY &ZS /liyt�. -r 1Q� / 1+
EXISTING
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7? D %D
PHONEA� ' l
BUILT -UP ROOF ❑
LICENSE
NUMBER S/
ASPHALT SHINGLES
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 Code, and my license is In full force and
do
effect. /
,�
License Class - � Lic. Number
WOOD SHINGLES
OTHER (SPECIFY)
Data Contractor —'
OWNER
-BUILD EC TI
I hereby affirm that I am exempt from the Contracto itense Law for the following reason.
PROPOSED
(Sac. 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
BUILT -UP ROOF ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractors License Law (Chapter B (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 ILA
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).):
I,
WOOD SHAKES ,
❑
[] 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 sate (Sec. 7044, Business and Profes.
slons Code: The Contractors 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 eycluri vely contracting with licensed contractors to construct
the project (See. 7 044, 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(s) licensed pursuant to the Contractor's License Law.
PROVIDE MFGR. INSTALLATION SPECS.
❑ I am exempt under Sec. ,S 8 P. C. for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION
PERMIT FEE
/7
_ ,J
L �
- 00
Building / U�
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 Coda, for the performance of the work for which this
permit is issued.
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Seismic
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section 3700 of
/
the Labor Code, for the performance of the work for which this permit is Issued. My Workers
Compensaticon Ins rents terrier antl Policy umber ere:
A I
Total ��
PERMIT AUTHORIZATION
DATE
Carrier `l Policy No. �L Y4W
CERTIFICATE OF EXEMPTION FROM WORKERS'
_
/ - y
3
COMPENSATION INSURANCE N.C.
(This section need not be completed It the permit is for one hundred dollars ($100) or lass.)
L/ 1 f r O
certify that In the performance of the work for which this permit Is Issued, shell not employ
any person in any manner so as to become subject to the Workers' Compensation Laws of Cell-
All roofs shlallldeMsOeefidid pribwto any rooting material being
fornia.
installed. If a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: 11, after making this Certificate of Exemption, you should become
subject in the Workers' Compensation provisions of the Leber Coda, you must forthwith comply
Applicant understands WIII I with all non Olnl
PP P y P
with such provisions or this permit shalrbo deemed revoked.
SOUfCe regUlatlOns.
I certify that I have read this application and state that the above Information Is correct. I agree
IO Comply with all clryand counryoNinancesand stare laws relating to building construction, and
All roof cove' "or better.
hereby authorize representatives of this city to enter upon the above - mentioned property for in.
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 .
SI ATUR A
(CANT E
of the granting of this permit.
-
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