R 5456 RIT
' APPLICATION FOR clTv of cuPERTINo
NUMBER R- 5456
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 700 DAYS OF PERMIT ISSUANCE OR
BUILDING ADDRESS
180 DAYS FROM LAST CALLED INSPECTION.
RESIDENTIAL COMMERCIAL OTHER
ow ER' HAZARDOUS FIRE AREA
C YES ❑ yes— understand that a Class A
NAME I of assembly is required.
NO Initial I.C.B.O.H
ADDRESS 5 0- - EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S _ /� .
NAME( IDS —C-sd�WS �0'1'/✓L R TO BE REMOVED TO BE RETAINED
ADDRESS e n �x 7� / TYPE OF ROOF COVERING
CITU 8 ZIP �
EXISTING /J,
PHONE BUILT-UP ROOF El ;
LICENSE
NUMBER ASPHALT SHINGLES ❑ ��
LICENSED C TRACTORS DECLARATION
I hereby affirm that 1 am licensed un r provisions of Chapter a(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my licence la In lull force and
effecl WOOD SHINGLES ❑
License Class C 39 Lie.Number 4 • 24(p
DateContract.,
OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors 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 la licensed pursuant to the provisions
of the Contractor's License Law(Chapter B(commencing with Section 700()of Division 3 of 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
a civil penalty of not more than five hundred dollars($500).):
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for Bele(Sec.7044,Business and Profes-
Iona 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 one year of completion,the owner-bullder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of eels.).
❑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 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 pursuant to the Contractor's License Law. PROVIDE MFG R.INSTALLATION SPECS.
E]I am exempt under Sec. ,B 8 R C.Mr this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
'
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, 1aa BUIIdIn
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this N' y
psiffelen
permit Is Issued. ` ® 9eiBmic
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of f'
the Labor Code,for the performance of the work for which this permit Is Issued.My Workers , 1 es as Q� Total
Compen Ion In urs a carrier and Policy number are:
Carder Policy No.uJYn — `L ^ (,,_ V
PERMI HORIZATION DATE
CERTIFIC TE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.D �^
(This sectlon need not be completed If the permit is for Otis hundred dollars($100)Or ISO .)
/
I certify that in the performance of the war k for which ihle permit is Iseuetlyl shell not amptoy
any person In any manner se as to become subject to thy�prkers'Compensation Laws of Cas- All roofs shall b i petted prior to any roofing material being
forms. installed. If a roof is installed without first obtaining an
Data/2-2-97 Applicant .Ce.. r inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: II,after making this Certificate of Exemption,you should become Applicant understands and will tom
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP ply with all non point
with such previsions or this permit shall be deemed revoked. Source regulations.
I certify that l have read this application and state that the soove information Is correct.l agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof cover'ngs to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes,
(We)agree to save,Indemnify and keep harmless the City of Cupertino against Ilabllltles,
judgments,costs and expenses which may in any way accrue against said Clry In consequence
. of the granting of this permit. SIGNM13M 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