R-5325APPLICATION FOR
REROOF PERMIT
CITY OF CUPERTINO
INSPECTION DIVISION
(408)777-3228
�I�J ��4S• L ! /61,t/ VES
NAME ❑
—
NO
ADDRESS
PHONE 7/ �ADOI
LICENSE /✓�����
NUMBER
I hereby affirm that I am licensed under prov i lona of Chapter 9 (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license is in full force and
effect.
License Class �.�.�_ Liu Number �/�/�//Ja
Data +�a.� —2 Contractor —_,I: S
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the fallowing reason.
Sec. 7031.5 Business and Professions Code: Any cityor countywhich requires a permit to
construct, alter, improve, to file signed
n repair any structure, prior to its issuance, also reproves the
of theant for such permit to flaw a signed statement that he Is licensed pursuant to the provisions
of me Contractor's License Lew (Chapter 9 (commencing with Section 7000) of Diodon 3 of the
Business and Professions Cotle) or that he Is exempt therefrom and the basis for alleged
exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the app epPllcent to
e civil penalty of net more than five hundred tlallere ($500).):
I, 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 (Sac. 7044, Business and Prufes.
signs Cotle: The Contractors License Law does not apply to an owner of property who builds or
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 -builder will he. the burden of proving that he did
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
apply to an owner of property who builds or Improves thereon, and who contracts for such projects
with a contractors) licensed pursuant to the Contractor's License Law.
❑ 1 am exempt under Sea ,B & P. C. for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following dectaratlom
-11 have and will maintain a Certificate of Consent to self -Insure for Worker's Compensation,
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
permit is Issued.
❑ I have and will maintain Workers Compensation Insurance, as required by Section 3700 of
.the Labor Code, for the performance of the work for which this p is issued. My Worker'
Compensation InsIurance carrier and Policy number or
Carrier �`[�^� Policy No.
CERTIFICATE CrF EXEMPTION FROM WORKERS' ,
COMPENSATION INSURANCE N.C.Q
(This section need not be completed If the permit Is for one hundred dollars is 00) or less.)
I certify that in the performance of the work for which this parmp Is issued, I shall not employ
any person in any manner so as to become subject to the Workers' Compensation Laws of Calk
fornia.
Date Applicant
NOTICE TO APPLICANT: II, after making this Certificate of Exemption, you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
with such provisions or this permit shaipbe deemed revoked.
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 bul lding construction, and
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spection purposes.
(We) agree to save, Indemnity and keep harmless the City of Cupertino against liabilities,
judgments, costs and expenses which may in any way accrue against said City In consequence
NUMB PERMIT 5325
PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
COMMERCIAL OTHER
and that a Class A
required.
Initial I.C.B.O.
NUMBER OF EXISTING COVERINGS
TO BE REMOVED Y TO BE RETAINED
TYPE OF ROOF COVERING
EXISTING
BUILT-UP ROOF ❑
ASPHALT SHINGLES
WOOD SHAKES
WOOD SHINGLES ❑
OTHER (SPECIFY) / 3 ❑
PROPOSED IO
BUILT-UP ROOF ��/
ASPHALT SHINGLES
WOOD SHAKES ❑
WOOD SHINGLES ❑
OTHER (SPECIFY) ❑
PROVIDE I.C.B.O. REPORT NO.
PROVIDE MFGR. INSTALLATION SPECS.
IAPPLICATION DATEI VALUATION I PERMIT FEE I
04 1 Building �
IUee 1 ^nom Seismic
Total
G/i PER AUTHORIZATION DATE
All roofs shall be inspected prior to any roofing material being
installed. If a roof is installed without first obtaining an
inspection, l agree to remove all new materials for inspection.
Applicant understands and will comply with all non point
source regulations.
All roof cove Ings be class' o Bitter.
SIGATURE UF AP ANT DATE
PRE -INSPECTION: PLYWOOD: IN -PROGRESS:
INSP. DATE - INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
DATE (INSP.
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION I
OFFICE COPY