R 5095 PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 5095
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
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAMEr V��..7a�..�p roof assembly is required.
NO ❑ Initial I.C.B.O.N
NDDRESS EXISTING ROOF COVERING
PHONE -' ' NUMBER OF EXISTING COVERINGS
CONTR O 'S
f t NAME
R� TO BE REMOVED TO BE RETAINED
�✓`` ADDRESS I/� , TYPE OF ROOF COVERING
CITY 8 ZIP -1,
- � 3 EXISTING
PHONE QBUILTUP ROOF
LICENSE -filNUMBER (J 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 0l the Business and Profeaaio a Cotle,end my licence Is In lull torte entl
effect. WOOD SHINGLES
License es / Lic.Number
Data Contractor
OTHER(SPECIFY)
R-BUILDER DEC ATI
I hereby a 114 that I a Ixopt rom the Contractor's License Law for the followPROPOSED AUG
react n. A/ �
(Sec.7031.5, usiness a d Professions Code: Any city or county which requires a permit to M
construct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF 6
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 eppllcent to '❑' l U
e civil penalty of not more than five huntlretl dollars($500).):
❑L 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 or offered for sale(Sec.7044,Business and Profen
alone Code:The Contractor's 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 exclusively contracting with licensed contractors to construct
the project(Sac.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 Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for this reason
owner Dale
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 sell-insure for Worker's Compensation, BUII
as provided for by Section 3700 o1 the Labor Code;for the performance of the work for which this Bull
permit
LJI^I
permit lave and eISn11C
❑ haus and will themaintainrt Worker's Cohe !0Ian Insurance,as required by Section 3700 of
_the Labor Code,for the performance of the wor for which this permit ie issued.My Worker's r Comp Ina a_ a carr d Policy num r are: '•7 '�'� Total
carr Policy PERMIT AUTHORIZATI DATE
CERTIFICATETION FROM WORKERS'
COMPENSATION
N INSURANCE N.C.I]
(This section need not be completed If the permit Is for one hundred dollars($100)or lose.)
I certify that In the performance of the work for which this permit Is issued,1 shell not em toy
any parson any mann r so as to become aub'ect to the Workers'Compens n Laws m�a11 All roof.^.Sha be sp ed or to any roofing terial being
forni installed. If a oof i installed without first ob aining an
Date d pant 'N inspection,I agree to remove all new materials for inspection.
NO APPLICA T: II,char making this Certificate of Exemption,you should co
subject to t Workers'C mpensation provisions of the Labor Code,you must forthwith com Applicant understands and will comply with all non point
with such pr visions or this permit shalCbe 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 rotating to building construction,and All roof coverings to be ass"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In. 1 _
spectlon purposes. ,
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
ludgm ante.coats and expenses which mey In any way accrue against sold City In consequence
of the granting of this permit. SIGNATURE OF APPL ANT A E
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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY