R-5729 ` PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 5 7 2 9
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1110 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
�l RESIDENTIAL COMMERCIAL OTHER
OWNERS HAZARDOUS FIRE AREA
L �`'�s� ry/s i 1 r VES ❑ 11 yes s I understand that a Class A
NAME/' A L�yft?!r mot assembly is required.
^ NO Initial- LC.B.O.H
ADDRESS ifs ftsOu EXISTING ROOF COVERING
_ fag NUMBER OF EXISTING COVERINGS
PHONE 6/d) 016
CONTRAC 'S
7 9 ,(�_L �A TO BE REMOVED TO BE RETAINED
NAME �a �/
ADDRESS !37 �N�// ^ ,, TYPE OF ROOF COVERING
CITY&ZIP r0 L�dl�Y9y EXISTING
PHONE J�6V�` �°�' 'r'"""�% BUILT-UP ROOF
LICENSEdd ASPHALT SHINGLES El
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 Cotle,and my license Is In full force and
effect.
WOOD SHINGLES El
License Class Llc.Number 4749 0
)� OTHER(SPECIFY) ElData �C� Opntraplpr
OWNER BUILDER DECLARATION PROPOSED
Bu
hereby elithat em exempt from the Contractor's License Law for the following reason.
(Sac.7031.5,Business and Professions Code:e: Any city or county which requires a permit to
construct,for
Improve,demolish,or repair any ntrthatre,prior to its issuance,also requires the BUILT-UP ROOF ❑
applicant for etch permit License flaw aChapt r 9(co m that he ishlicensedSectio pursuant m the provisions
of the Contractor'sssions Lew(Chapter 9(commencing therefrom
Section]000)of Division 3 of the
Business and Professions Code)or that he Is exempt therefrom and the beats for the alleged ASPHALT SHINGLESt�
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).): WOOD SHAKES /
[:]I,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 sale(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 has own employees,provided that 7 ^ x
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.).
E]1,as owner of the property,am excl ueavoiy 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 wnlractore)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: p� p ,� w
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, P A I D Building r1--7/� 1/—
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Nov BeIBmiDQ
❑ have and will the pelrf Worker's Compensation thework
for
Insurance,as required by Section 3700 of �[flgp ��
-the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's Into
Total
Compenstiof.f�Insurance carr r end Policy number are:
Carrier- — Policy Nllba12 �� ITY&P14111MUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' -
COMPENSATIONINSURANCE N.C.0
(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 shell not employ
any person In any manner so as to become subject o 1e Wwrkers'Compen atlon Laws of Cali- All roofs shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date 1i Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should b Applicant understands and Will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith ply PP P Y
with such provisions or this permit shall 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 Tawe relating to building construction,and All roof overt ngs to b=ssC" better.
hereby authorize representatives of this city to anter upon the above-mentioned property for In.spection purposes.(We)agree to save,Indemnity antl keep harmless the City of Cupertino against liabilities. `J
judgments,costs and expenses which may In any way accrue against said City In consequence g
of the granting of this permit. l NATURE OF APPLICANT 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
OFFICE COPY