R-5804 PERMIT R_ 5804
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
RESIDENTIAL COMMERCIAL OTHER
OWNER'S(�I HAZARDOUS FIRE AREA
NAME I U "'"' I YES [D If yes-I understand that a Class A
not assembly Is required.
NO Initial I.C.B.O.q
O �'`y --
ADDRESS / I(I� � EXIST R F COVERINQ
PHONE D $ r 2S g ) O NUMBER OF EXISTING COVERINGS Qau�
CONTRACTOR'S
NAME IV 0. ) tl�� �JJ� I TO 13E REMOVED V ps TO BE RETAINED psr p
ADDRESS f�s�8 S t N I NC�,Q I` TYPE OF ROOF COVERING
CITY&ZIP
EXISTING
PHONE BUILT-UP ROOF
LICENSE
NUMBER O S ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provislons of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license is in lull force and
El <�
effect. ?
C 3 WOOD SHINGLES ❑ Yq
License Class Lic.Number L
Date If 2 S- Contractor �C. OTHER(SPECIFY) ❑
OWNER-BUILDER DE RATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,after.improve.demolish,or repair any structure,prior to its issuance,also requires the BUILT-UP ROOFOA I ID ❑
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 9BttNGL f
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to ''��G dee77
a civil penalty of not more than five hundred dollars($500).): IIEU
WOOD 81'��,--.5
❑l,as owner of the property,or my employees with wages as their sola Compensation,will do t((Jt El
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profes. �' /' �Ur
stone Cotle:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES �k)fNU ❑
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-budde(wlll 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(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, BUlld1
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this Sv d V°i
permit is Issued. 1' �S �� Seismic
❑1 have and will maintain Workers Compensation Insurance,as required by Section 3700 of I
the Labor Code,for the performance of the work for which this permit is Issued.My Workers
Compensation Insurance carrier Policy num ar are: Total
Carrier SM Q f l' IA Policy No. I y 9 O PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed if the permit is 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 SEPE
any person In any manner so as to become subject to the Workars'Compensation Laws of Cali- All roots shallbe inspected prior to any roofing material being
fornia. q� tL n t / installed. If a roof is installed without first obtaining an
Data
/)_ s Applicant `�yyYy'—,t'�" �I�-C� 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
subject to the Workers'Compensation provisions of the Labor Cotle,you must forthwith comply pp p y 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 relating to building construction,and All roof coverings to beclass"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In- t
spection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino agalmn liabilities,
judgments,costs and expenses which may in any way accrue against said City In consequence 3I N TUBE OF APPLICANT ATE
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