R 5013 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER .R
- 5 013
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
•
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
WI180 HAYS FROM LAST CALLED INSPECTION.
BUILDING
ADDRESS I l/]��
� 4 O^ w RESIDENTIAL—X—COMMERCIAL OTHER—
ii
OWNER'S HAZARDOUS FIRE AREA
VES El 11 yes—I understand that a Class A
NAME- roof assembly is required.
NO ❑ Initial I.C.B.O.It
ADDRESS �. � EXISTING ROOF COVERING
PHONE
NUMBER OF EXISTING COVERINGS I
CONTRACTOR'S
TO BE REMOVED ! TO BE RETAINED
NAME VL
C�
ADDRESS2 , �� „ _0 t0 _ I TYPE OF ROOF COVERING
CITYBZIP 43o:s k_s✓ : a'V7T� /�.G� EXISTING .
PHONE v /y� 7 70 -036 z,
BUILT-UP ROOF ❑
LICENSE 4167117
NUMBER 0 ASPHALTSHINGLES ❑
LICENSED CONTRACTORS DECLARATION
hereby affirm that I em licensed under provisions of Chapter g(<ommendng with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect. 9 J WOOD SHINGLES
License Close / Lie,Number ` E]
Date 479,011Contractor
OTHER (SPECIFY) ❑
OWNER-BUILDER DECLARATIO PROPOSED
hereby affirm that I em exempt from the Contractor's 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 Contreotor'e License Lew(Chapter a(commencing with Section 7000)of Division 3 01 the
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of not more than five hundred dollars($500).): 47{3
01,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑ 199
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes. (.11-Y
dons Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑ UI- �UYtryl FU
improves thereon,and who does such work himself or through his own employees,provided that lr
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) El
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 Contractees 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(s)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION $PFOB.
[:]I em exempt under Sec. ,B 8 P.C.for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm untler penalty of perjury one of the following declaration; ^.
❑1 have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, Building
as,provided for by Section 3700 of the Labor Cotle,for the performance of the work for which this g
perm) le lasuotl. [—
have end will maintain Worker's Compensation Insurance,as required by Section 3700 of ",J �j �Z SBISn11C
r the a or Cotle,for the performance of the work for which this permit Is Issued.My Worker'sComper"'0 �`'In mote carrier en Policy number are: Total
'
Carrier ry � '1211 NO. KERS' 06 PERMIT AUTHORIZATION DATE
AI
CERTIFICATE
COMPENSATION INSURAN EWORN.C.❑
(This section need not be completed If the permit la for one hundred dollars($100)or less.)
1 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 Cell- All roots 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.
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 Applicant understands and will comply with all non point
with such provisions or this permit shalRbe doomed 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 relating to building construction,and All roofco erin obe class"C"or better.
herebyauthorize representatives of this city 10 enter upon the above-mentioned property for In.
hereblon purposes. of//yJ
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
judgments,coats,end expenses which may In any way accrue against said City In consequence
• of the Oranungatthis parm0. SIGNATURE 9FAPPLICANT 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