R 5255•
•
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PERMIT Rxx 5255
APPLICATION FOR CITY OF CUPERTINO NUMBER
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.
BUIIILLDDING ADDRESS
-
1' y�
O� 1Y
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U y I
RESIDENTIAL V COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
a b Mu��
YES ❑ If yeas I that a Class A
NAME
roof assembly is required.
assembly is req
NO InlUal I.C.B.O. a
aC) yes
EXISTING ROOF COVERING
ADDRESS
PHONE y 01
NUMBER OF EXISTING COVERINGS I
-
TO BE REMOVED t TO BE RETAINED
CONTRACTOR'S
NAME
ADDRESSy
TYPE OF ROOF COVERING
CITY fiZIP 1
-
Lib—
EXISTING
�aA�
PHONE
BUILT-UP ROOFLICENSE
NUMBER
/
ASPHALT SHINGLES [1 fC�A'P l�l`p
I
LICEN 13
CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license Is in full force and
WOOD SHAKES , �g,x
d,]\
exact. Q C � 51
WOOD SHINGLES ❑ 1iZ
License Class 6) Lic. Number
a
y�.�,���,�,
Date — `{l Contractor S.M]1L.fT n
1srac,l cx
OTHER (SPECIFY) ❑ -
OWNER -BUILDER DECLARATION
6
PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
,ps
(Sec. 7031.5, Buelness and Professions Cotle: Any city or county which requires a permit to
pa
demolish, or re any structure,seance,
prior toits Issuance, alsorequireslns
BUILT-UP—ROOF ® ❑
applicuct,elter,Improve, to filesindstaementrthate,
construct for such permit to Ills a statement that he is licensed the provisions
of the Contractor's License Law (Chapter 9 (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
,¢I/ip�B]';;��SLSL{°DsINN//�//��"
ASPHAL 1
exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars ($500).):
CY ��
❑ I, as owner of the property, or my employees with wages as their sole compensation, will do
WO JffiAl . ❑
the work, and the structure Is not intended or offered for sale (Sec. 7044, Business and Profes.
rCry
alone Code: The Contractor's License Law does not apply to an owner of property who builds or
r�f�U
Improves thereon, and who does such work himself of through his own employees, that
WOOD SHINGLES ❑
provided
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 pu rpoae of sale.),
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to construct
the project (Sec. 7044, 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.
[II am exempt under Sec. ,B 8 P. C. for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION
PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑ I have and will maintain a Certificate of Consent to self -insure for Workers Compensation,
as provided for by Section 3700 of the Labor Cotle, for the performance of the work for which this
BUjldln�
permit sued.
Cave
^
ID,r-hl iy
O. �"(
1/
$elSrrllC
and w111 maintain Worker's Compensation Insurance, as required by Section 3700 of
I
,ins Labor Code, for the performance of the work for which this permit to Issued. My Worker's
Compensation Insurance carrier endP licy number are:
Ir
Total
Q����
Carrier Fur Policy No.l�zazi lta
PERMIT AUTHORIZATION
DATE
CERTIFICATE EXEMPTION FROM WORKERS'
to ��
COMPENSATION INSURANCE N,C.p
(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
All roofsthal be Inspected prior to any roofing material being
any person In any manner so as to become subject to the Workers' Compensation Laws of Cell.
fornia,
installed. If a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
subjeNOTICE
to the WorkersTO ' Compen, after sation n provisionls of ttheficate of Laborr Code, Exemption,
must forthwshoulltlhbecome omply
Applicant understands and will comply with all non point
with such provisions or this permit shalgbe 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 coverings to be class "O O be r.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spectlon purposes.
,ny,
(We) spree to save, indemnity and keep harmless the City of Cupertino against liabilities,
ludpmenta,
thcosts ntl expenses which may In any way accrue against geld City In coneequenca
d e granting of this permit.
SI NATU E OF VILll — 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
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