R 5771 r
PER
APPLICATION FOR CITY OF cuPERTINo
NUMBER R- 5771
REROOF PERMIT INSPECTION DIVISION' PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Me DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
S
t/ PI
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME roof assembly is required.
NO Initial I.C.B.O,q
ADDRESS I EXISTING ROOF COVERING
PHONE ` NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
�f TO BE REMOVED TO BE RETAINED
NAME
ADDRESS TYPE OF ROOF COVERING
CITY III; /f,/ EXISTING
PHONE .�-Kl..
s BUILT-UP ROOF ❑
NIUMBER ASPHALT SHINGLES ❑ q
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
effect. WOOD SHINGLES
License Class�_ Lic.Number J
Dale lO'� � Contra-tor�Z1 OTHER(SPECIFY) ❑
OWNER-BUILDER DECLAROM?, PROPOSED
I hereby affirm that I am exempt from the Conlrectors 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 BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to 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 ASPHALT SHINGLES
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($500).):
C]1.as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended 0,offered for sale(Sec.7044,Business and Profes-
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES
Improve$thereon,and who does such work himself or through his own employees,provided that ❑
such Improvements are not Intended or offered for$ale.II,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 puPose 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 contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
El em exempt under Sec. ,B 8 P.O for this reason
Owner Date.
WORKER'S COMPENSATION DECLARATION APPLIC TION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: A
❑1 have and will maintain a Certificate of Consent to self-insure for Workers Compensation, W ®® Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this /s�
permit is issued. V
❑I have and w111 maintain Worker's Compensation the workfor Insurance,as required by d.My
Workers
of C� n. �w $eISR11C
.the Labor Code,for the performance of the work for which this permit Is issued.My Workers G/�
� v �
Compensations Insurance�iernd Po ecy number are: /� C, Total
Carrier Com. — ! {, — Policy No.jS24�. PEAlgil UTHORIZATION DATE
CERTIFICATEEN COMPENSATION
SURANMWORKERS'
COMPENSATION INSURANCE N,C.]
(This section need not be completed If the permit Is for one hundred dokare($100)or less.)
1 certify that In the performance of the work for which this permit Is Issued,I shall not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Cali. All roofs shall be inspected prior to any roofing material being
fornia. r installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
subject to thICE eOWorkereCCompefnsatlorn provisions of the11Late of borr Code,Exemption,
1u must fonewne comply Applicant understands and will comply with all non point
with such provisions or this permit shallibe deemed revoked. source regulations.
I certify that I have read this application and state that the above Inlormation 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°C°Or er.
hereby authorize representatives of this city to anter upon the above-monlloned property for in.
`
hereby
purposes.
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities,
judgments,costa and expenses which may In any way accrue against said City In consequence
of the granting of this permit. SI U OF APPLI DAT
• 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