R 5151 PERMIT R_ 5151
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
WI180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS �
1ht �U O ( RESIDENTIALJ/(�_COMMERCIAL OTHER
OWNER'S�� O HAZARDOUS FIRE AREA
/Y Z-- oN �`� VES ❑ If yes—I understand that a Class A
NAME
/'��cof assembly is required.
_ _ /� N�f- Initial I.C.B.O.k
ADDRESS 1 LK 9 {1 ) P Aut r 5-17 �LI EXISTING ROOF COVERING
PHONE (' V NUMBER OF EXISTING COVERINGS ,
CONTRACTOR'S1CL'C` r
NAME ()n/s fzO V t% ) TO BE REMOVED_TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
�L �S, P
CITY&ZIP
.
( � !� r•� EXISTING
PHONE— "'IU �•-•b�Z UM " ) 1 BUILT-UP ROOF ❑
LICENSE
NUMBER b 2 �� ASPHALT SHINGLES (�
LICENSED CONTRACTORS DECLARATION /
I hereby affirm that I em Ilcensetl under provisions of Chapter B(commencing with Section LHE
HAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
anent' _ L HINGLES ❑
LicenseClass
�,LC Uc.Num ber Z'
Date—!I/OJ.LJ3L—Contractor CIOWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the(allowing 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 Llcense Law(Chapter B(commencing with Section 70001 of Division 3 of the
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALTSHINGLES
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($500).): WOOD SHAKES
C]1,as owner of the property,or my employees with wages as their sole compensation,will do ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Pmfes-
slons Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,provided that ❑ _
such Improvements are not intended or offered for sale.If,however,the building or Improvement
Is sold within one year of completion,the owner-buAder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to Construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor($)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,8 It P.C.for this reason
Owner oats
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
oI n re by affirm under penally of perjury one of the following declaration: n •('
heve and ill maintain a Certificate of Consent to sddnsure for Worker%Compensation, F,o '^ BUIlding
eeeeee����55 roJ�d���iidad for Section 3700 of the Labor Code,far the performance of the work for which this (�, PB
permit is issued. )
$ C]I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of Seismic _
the Labor Cade,for the performance of th work for which this permit Is issued.My Worker's r(, -11 V Total
Companae an Insure carr($�end Policy umber ere: (, V
carrier Policy No' 4 PERMIT AUTHORIZATION DATE
1 CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.p
(This section need not be completed if the permit is for one hundred dollars($100)or lees.)
1 certify 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 subject to the Workers'Compensatlon Laws of Cali. All roofs shall be inspected prior to any roofing material being
forma. installed. If a roof is installed without first obtaining an
Dale 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 shaipbe deemed revoked. source regulations.
I certify that I have read this application and state that the above Information Is correct.)agree
to comply with all city and County ordinances and state laws relating to building construction,and All f overings to be class"C"or better.
herebby
hereauthorize representatives of This city to enter upon the above-mentioned property(ar In
y
purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against IIeblllllee,
ludgments,costs and expenses which may In any way accrue against said Clry In consequence
of the granting of this permit. SIGNATURE 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
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