R 5018 PERMIT -1
R_ 5 01 .
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1 DAYS PERMIT ISSUANCE OR
WI F DANS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
76 RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
1r_ VES ❑ If yes—I understand that a Class A
ES k
NAMO UJ MQ Y1 roof assembly is required.
NO ❑ Initial I.C.B.O.k
ADDRESS 0 Mli EXISTING ROOF COVERING
PHONE - • NUMBER OF EXISTING COVERINGS
NAME [ S ( a V�**1/ �GO /h A • /� TO BE REMOVED TO BE RETAINED
ADDRESS P��X I / (7 �O ,� (JS /' R.10S 04 TYPE OF ROOF COVERING
CITY&ZIP 1" G� C? T
p 031 EXISTING
PHONE �D[� •�59-12 -3 BUILT-UP ROOFLICENSE
❑
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that em si nes antler provisions of Chapter y(commencing with Section WOOD SHAKES
7000)of Division 3 0l the Business end Professions Code,and license isin lull force and
effect. /1 GWOOD SHINGLES ❑
License Class l Llc.Number
Data Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from the Contractor's License Lew for the following reason,
IS
7031.5,Business and Predations 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 `rpml
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
al the Contractors License Lew(Chapter B(commencin7 with Section 7000)of Division 3 of the
Buslness and Professions Code)or that he Is exempt Iharefrom and the basis for the alleged ASPHALT SHINGLES yGL
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 sale compensation,will do ❑
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profes.
cions 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 and year of completion,the owner-budder will have the burden of proving that he did OTHER(SPECIFY) El
build or Improve for purpose of sole.).
❑I.as owner of the property,em exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's 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 derSe pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS
❑I em exempt antler Sec. ,B 6 P.C.for this reason
Owner Date — I
APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I her
aKlrm antler penalty of perjury one of the following tle[leretlon: �• G� A �
eve entl will melnteln a Certl/iters of Consent to eel4lnsure for Worker's Compensallon,
ae prov lorby Section 3700 of lha Labor Cotle,lorthe performance of me work forwhl[h mle
permit laeuatl. Jut 0 0 4 3 0.6 S smlc
It and will melnteln Worker's Compansetlon Inaurence,ee requlretl 6y Section 3700 of U q^ [
I Cotle,for the performance of the work for which this permit Is laeuatl.My Worker's C/� t U Total
ompen Ion Inaurence cartler end�Icy number ere: �II �� r Or r
DomerICA FROM a PERMIT-AUTHORIZATION DATE
CEITrIFCOM EN EXEMPTION FROM WORKERS'
COMPENSATION the ON INSURANCE N.C100)o
(Thio section need not be completed If 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,I shell not emloy
any person in any manner so as to become subject to the Workers'Compensation Levee of Kil. All roots Shall blevinspected 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 Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pp p Y p
with such provisions or this permit shell 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 relating to building construction,and All roofs I gs to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spectlpn purposes. -
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, �i_oi I ,— 3B
judgmeme,costs end expenses which may In any way accrUS against mid City 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
OFFICE COPY