R 5866 APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 5866
INSPECTION DIVISION PERMITEXPIRATION
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 ADDRE�SSS.��3
eci
eh • RESIDENTIAL COMMERCIAL '✓/ OTHER
OWNER'S HAZARDOUS FIRE AREA
YES El If yes—I understand that a Class A .
NAME d b G• roof assembly is required.
NO ❑ Initial- I.C.B.O.#
ADDRESS p 6 EXISTING ROOF COVERING
PHONE Ol9 ',c NUM BER OF EXISTING COVERINGS. -
CONTRACT 'S
TO BE REMOVEDy TO BE RETAINED
NAME
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP Zh. -
p p 9f EXISTING
PHONE 0_0_%96ff,� BUILT-UP ROOF
LICENSE
NUMBER 122M ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby eHirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license is In full force and
effect G 7� WOOD SHINGLES ❑
License Class Lia Number
Date olContractor OTHER (SPECIFY) ❑
OWNER-BUILDER DECLARA N PROPOSED
I hereby affirm that I em exempt from the Contractor's License allowing reason.
(Sac.7031.5,Business and Professions Code: Any city or count on requ r
construct,altar,Improve,demolish,or repair any structure,prior to l aone.,a mime the UILT-UP ROOF
applicant for such permit to file a signed statement that he Is Loans such Islon
' of the ss and
License Lew(Chapter a(commencing with om Old Tor t of m YTHER
SPHALTSHINGLES ❑Business and or'sLice se Code)or that he to exempt Therefrom a l d far Iha elof ed thexemption.Any violation of Section 7031.5 by any applicant for a su ft glicant to
a civil penalty of not more than five hundred dollars($500).): Vii U ''�too((]]pp❑I,avownerolthepropertyormyempioysdswithwagesas rablecompensation,w111b3s7VOOD SHAKES ❑the work,and the structure Is not intended or offered for sale(S .7044,Business and Profes.
sions Cotle:The Contractor's License Law does not apply to an w rot property who builds orOOD SHINGLES ❑Improves thereon,and who tloes such work himself or through hlmpiayeee,provldetl thatsuch Improvements are not Intended or offered for sale.If,howo rt vememIe sold within one year of completion,the owner-builder will have the burden opr (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(Sec.7044,Business and Professions Code:The Contractors License Lew 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.
❑I am exempt under Sec. ,B 8 P.C.for this reason
OwnerDate
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the fallowing declaration:
❑I have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, Buildin 7'
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this g
permit le ued. D ..QR O
ova end will maintain Worker's Compensation Insurance,ore required by Section 3700 of 1 r� /`v I �O•� SeISfIIIC /r
rt Labor Code,for the performance of the work for which this permit le issued.My Worker's f�f`shy C97 O
Compensatl n urance carrier and Policy number are: J Total
Carrle S PoIlcyNo. u,rTil�S7ab98 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.O(] q
(This section need not be completed It the permit Is for one hundred dollars($100)or leas.)
I certify that In the performance of the work for which this permit Is issued. shall not employ
any person in any manner so as to become subject to the Workers'Compenaelton Lewa o1 can- All roofs shall be inspected prior to any roofing material being
fornix. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and will cam
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP ply with all non point
with such provisions or this permit shall be 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 raising to building construction,and All ro coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
_ ap purposes.
we)
(We)agree to aave.Indemnify and keep harmless the City ori Cupertino against sequence �,� Q
of the gran costs and expanses which may In any way accrue against said City In consequence
Dane granting of permit, SIG ATURE UFAPPLICANT 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY