R 5775 ' t0 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
1B DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS RESIDENTIAL X COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME__ • % "�'y roof assembly is required.
NO ❑ Intiial I.C.B.O.#
ADDRESS-16 Gt�� EXISTING ROOF COVERING
PH )�OONE SS Z,Z� NUMBER OF EXISTING COVERINGS
CONTRAC 'S
NAME TO BE REMOVED____L_TO BE RETAINED
if ADDRESS ,/�. � n /yDa /1L) A/&b LYPE OF ROOF COVERING
CITU&ZIP LG)1 tCoG 7 (f",L�(� 7YJ�
f/�,,` EXISTING
PHONI" i �I 3 3 7-3BUILT-UP ROOF ❑
LICENSE
NUMBER 5-2-76O ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECIARATION
I hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES
]0001 of Division 3 of the Business and Proleselone Cotle,and my Ilcenae Is I�U�ll force and
effect. ? d 7 WOOD SHINGLES ❑
License Clesa J Lic.Number
Date LI Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARA ON
1 hereby affirm that I am exempt from the Contractors License Law for the following reason..
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to t.. .
construct,alter,Improve,demolish,or repair any structure,prior to its Issuance,also requires the B IT-UP ROOF O ❑
applicant for each permit to flaw a signed statement that g is licensedSection
pursuant to the provisionsofthe S
of the ss and Contractor's License Lew(Chapter S(commencingwitheref Section 7000)of for the 3 of the QT
Business and Professions Code)or that he as exempt antforam and the baste for the alleged ASPHALT SHINGLEOS�
exemption.Any violation of Section 7031.5 by any applicant for a permit eubleala me applicant m
a civil penalty of not more than five hundred dollars($500).1: v
F)1,as owner of the property,or my employees with wages as their sola compensation,will do WOOD SHAKES ; ❑
the work,and the structure is not intended or oflered for sale(Sec.7044,Business and Protea- J
alone Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHING t
Improves thereon,and who does such work himself or through his own employees,provided that .,) ❑
such Improvements are not Intended or offered for sale.It,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.7044,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 contrach iei licensed pursuant to the Contractors License Law. PROVIDE MFG R.INSTALLATION SPECS.
❑I am exempt under Sec. ,B&P.C.for this reason
Owner - Date APPLICATION DATE VALUATION PERM FEE
WORKER'S COMPENSATION DECLARATION
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, � Building
O
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this i
per 1 le Issmd. n 9 / � O
have end will maintain Worker's Compensation Insurance,as required by Section 3700 of • 3Q Seismic ---f--�
-in Labor Code,for the performance of the work for which this permit Is issued.My Workers
C mpensation Insurance carrier entl Policy number are: Total
Carrier PolicyNo.5�_//ZS PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.O�
(This section need not be completed If the permit Is for one hundred dollars($100)or leas.) �(� s�f�O q
I certify that in the performance of the work for which this permit Is Issued,I shall not employ r•.
any person in an manner so as to become subject to t tare'cam creation Laws of call- All roofs shall be inspected prior to any roofing material being
ionic' 5. 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: If,after making.this Ce locate of Exemption,you should become
subject to the Workers'Compensation provisions of the Labor Coda,you must forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shelrlbe deemed revoked. source regulations.
I certify that I have read this application and state that the above Information Is correct.I agree
to hereby ellrepty end secountyordinances and entelaws nthrelating nce-me tionsding property
All roof COyerin SCO be class "Or better. j9 d
herebyauthorizepure representatives al this city to enter upon the above-mentioned proDerry for In.
ape<tlon 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 cons--------
of the granting of this permit. SIGNATURE APPLICANT DATE
PRE-INSPEl 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