R-5619OFFICE COPY
PERMIT
R- 5619
APPLICATION. FOR CITY OF CUPERTINO NUMBER
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
t
t L
RESIDENTIAL COMMERCIAL OTHER
O ER's _ .
1
HAZARDOUS FIRE AREA
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YES ❑, Class
NAME V1='�-t
`f�1
�oyoF assembly srequireed
NO J Initial_ LC.B.O. If
_hy-AIA
S102, :5, -Z 1 e�1C /�y t _
EXISTING ROOF COVERING
ADDRESS—y
,
NUMBER OF EXISTING COVERINGS
rrW/123-IS 25 �Jj) 3y
PHONE`
Y,�S
CONTRACTOR'S
'
TO BE REMOVED TO BE RETAINED
NAME
TYPE OF ROOF COVERING
ADDRESS
CITY & ZIP
EXISTING
PHONE
❑
BUILT-UP ROOFLICENSE
NUMBER
ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am Ilcansetl 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
OTHER (SPECIFY) ❑
Data Contractor
PROPOSED
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the following reason.
(Sac. 7031.5, Business and Professions Code: Any city or county which requires a permit to
construct, alter, improve, demolish, or repair any structure, pilar 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 s1 Section 7031.5 by any applicant for a permit subjects the applicant to
a 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 Profes-
sions Code:Tha Contractor's License Law does not apply to an owner of property who builds or
WOOD SHINGLES El
thereon, and who does such work himself or through his own employees, provided that
such Improvements are not intended or offered for sale. It. 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 (Sec. Business and Professions Code: The Contractor's License Law does not
PROVIDE LC.B.O. REPORT NO.
apply to an owner of property who builds or Improves thereon, and who contends for such projects
with a contractoga) licensed pursuant to the Contractor's License Law,
PROVIDE MFGR. INSTALLATION SPECS.
I am exempt under Sec. ,B 8 P. C. for this reason
11-1 owns DataAPPLICATION
DATE
VALUATION
PERMIT FEE
WORkEpirs"c6mPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:'
Fl I have and will maintain a Certificate of Consent to sell -insure for Worker's Compensation.
Building
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
permit is Issued.
(L( (�x(�
UN �uu
JUN-
Seismic.
F7 have and will maintain Worker's Compensation Insurance, as required by Section 3700 of
.the Labor Code, for the performance of the work for which this permit Is Issued. My Worker's
Total
Compensation Insurance carrier and Policy number are: CI
V
LKI INU
PERMIT AUTHORIZATION
DATE
Carrier Policy No.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed II the permit is for one hundred tl011ars ($100)100) or less.)
V /vow/J,• `L
'� J
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 to the Workers' Compensation Laws of Call-
All roofs shall be inspected prior to any roofing material being
fornia.
installed. If a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
Applicant understands and will comply with all non point
PP P Y P
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
with such provisions or this permit sh iltbe deemed revoked.
source regulations.
I certify that I have read this application and slate 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 to be class "C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
sp purposes.
Ate,/L� / G,
(We) agree to save, Indemnity and keep harmless the City of Cupertino against liabilities,
(We)
w ..�//�I
`� /
judgments, costs and expanses which may In any way accrue against said City in consequence
SIGNATURE OF APPLICANT D
of the granting of this permit.
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