R 5913 PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 5 913
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
IN DAYS FROM UST CALLED INSPECTION.
BUILDING ADDRESS
I7 /fit
D// / ' Ile- Y/ / RESIDENTIAL COMMERCIAL - OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ II yes—1 understand that a Class A
NAME �� �6 root assemby is required.
c NO ❑ Initial I.C.B.O.p
ADDRESS���ZT�/ fq �� EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S t'
TO BE REMOVED I TO BE RETAINED
NAME
ADDRESS o � �r + �`1� TYPE OF ROOF COVERING
CITY&ZIP �S�j 7 �T�/y— /J V 3Sr
2 ��./ EXISTING
(fI/P
PHONEo ,�; v— f�1/�O BUILT-UP ROOF ❑ /s
LICENSE El
ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter B(commencing with Section WOOD SHAKES
7000)of Dlvlelon 3 of the Business and Professions Code,and my license Is In lull force and '7
enact. WOOD SHINGLES ❑ `C S//
License Class Number `
Dere contractor
OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from the Contractors License Lew 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 Lew(Chapter 0(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 ASPIA-T�SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit Subjects the applicant to 1" .44I,
e civil penalty of not more than five 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 Plates-
Improves
Code:The Contractor's License Law does not apply to an owner of property who builds or $ ❑
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 '�y r �
Is sold within one year of completion,the owner-builder will have the burden of proving that he did bTHER JSPECIFY) EJ build or Improve for purpose of sale.). ,
❑1,as owner of the property,em 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(a)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Dere
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: - /�.-I
E]I have and will maintain a Certificate of Consent to self•raure for Workers Compensation, ��
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this Building /
1� /� smm
par IIS leeuetl. (Or Seismic
I hove entl will maintain Workers Compeneetlon Insurance,ee requlretl by Section 3700 0l
,t Labor Code,for the performance of ins work for which this permit le Issued.My Workers
omDeneetlonL/ineurenc carrier end Policy nu erere: �..f/ Total �3
Cantor CERTIFICATE OF EXEMPTION FROM WORKERS'. 0�x PERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE N.C.p D e, ' y' ' ! /�
(This section need not be completed If the permit Is for one hundred tlollers($100)or less.) 'I I( �(�l/
I certity 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 eubjectLlo theWorlr ra'Compensad Lawa of cell. All roofs shall be inspected prior to any roofing material being
forma. installed. If a roof is installed without first obtaining an
Date-I Applicant �fExemqq inspection,I agree to remove all new materials for inspection.
NOYsubjects to the Workers'Compeneetlon provisionafter makingls of thelLabor Code,f o n mi rInwlIhbcomply Applicant understands.and will comply with all non point.
with such provisions or this permit ehalibe deemed revoked. source regulations.
I certify that I have read this application and stale 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 be class" rbetter.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
apache)purposes.
agree
(We)agree to Save,expenses
and keep harmless the Clry ai Cupertino against liabilities, (!Yn
of I manta costs and expanses which may In any way accrue against said Clry In consequence
of tRe granting of Parma. SIGNATURE O PLIC DAT
PRE-INSPECTION: PLvwooD: 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