R 5495 � 75yoG
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 5495
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 P MIT EXPIRES IF WORK IS NOT STARTED
THIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
B�j05ESS
.3 o
RESIDENTIAL COMMERCIAL OTHER
OWNER HAZARDOUS FIRE AREA
NAME VES ❑ Ifyes
a Class A
f assembly is requiiretl
NO Initial I.C.B.O.x
ADDRESS_/Q 5 3 Q S /h e EXISTING ROOF COVERING
PHON 2 — S NUMBER OF EXISTING COVE GS r
CONTRAC R'S
NAME ®S TO BE REMOVED TO BE RETAINED
ADDRESS / �1J�! h`y - TYPE OF ROOF COVERING
CITY&ZIP '/,/ rt
EXISTING
PHONE �UQ 3J f' �!�— BUILT-UP ROOF ❑
LICENSE
NUMBER � T - ASPHALT SHINGLES ❑ z•.'iCJ
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em Ilcensetl under provisions of Chapter 9(commencing with Section WOOD SHAKES J
7000)of Division 3 of the Business and Professions Code,and my license Is In lull roe and /^
enact. WOOD SHINGLES ❑ 7
License Class JC�__. Lie.Number
Date Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION 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,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 License Law(Chapter 0• (commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he Is exempt therefrom and the basis for the ellegetl ASPHALT SHINGLES ❑ -
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500).):
❑I,as owner of the property,or my employees with wages as their solo compensation,will do WOOD SHAKES
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Proles.
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 .moi
is 5 Id within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) u/W r
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct �7 /
the project(Sec.7044,Business and Professions Code:The Contractor's License Lew does not PROVIDE I.C.B.O.REPORT NX x_5/!i
apply to an owner of property who builds or Improvos thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractor's License Lew, PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 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, BUI din
as provided for by Section 3700 of the Labor Coda,for the performance of the work for which this 9
er laieeued. A� 4�� Seismic
I have and will maintainmannWorkers f the work
for which this
as required by Section 3700 of /ppl�rrps����
ih L s Code,for the Mar
and of the work for which role permit Is laeuetl.My Worker�a
mpenset Insu nc rrlor entl Policy number are: GI'of� t / Total
arrier Policy No. AUTHORIZATION DATE
RKE
CERTIFIC OF EXEMPTION FROM WORS' R0R0564V' a
COMPENSATION INSURANCE N.C.❑ 5 TJ
(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 shall not employ
any person In any manner so as to become subject to the Workers'Compensation 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
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 Allcant understands and will comply
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 shalt be 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 roof coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spectionpurposes.
(We)
(We)agree s save;Indemnify and keep harmless wa Ica City ni Cupertino against liabilities,
ofjudgments,the gran costs and expenses which may In any way accrue eBelnst said City In consequence
of the granting of this permit. _ SI URE 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY