R 5829 APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 5829
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 160 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS /^, �' /
0 ,(/ CSMI R ✓ESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
J ` �, J - YES ❑ It yes-I understand that a Class A
NAME roof assembly is required.
- - - NO Inigal I.C.B.O.W
ADDRESS EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S _ ^ -
DI TO BE REMOVED TO BE RETAINED
NAME
ADDRESS 4PE OF ROOF COVERING
CITY&ZIP
EXISTING
PHONE BUILT-UP ROOF ❑
LICENSE
NUMBER ` ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES ❑ /
7000)of Division 3 of the Business and Professions Code,and my license is In lull force and
e
License
iaffect.
❑ x�
Lcenn se Class Lic.Number WOOD SHINGLES
- Date Contractor
OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's 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 Is licensed pursuant to the provisions
of the Contractors License Law(Chapter a(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 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 ae their sole compensation,will do WOOD SHAKES
the work,and the structure Is not Intended or offered for safe(Sec.7040,Business and Proles-
alone Code:The Contractors 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-builder will have the bu rden of proving that he did OTHER(SPECIFY) El
build or Improve for purpose of sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sac.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 buildsor Improves thereon,and who Contracts for such projects
with a contractor(s)licensed pursuant to the Contractor's License Law. �(�VIb�MFGR.INSTALLATION SPECS.
❑f am exempt under S ,B 8 P.C.for this reason
WORKER'S COMPENSATION DECLARATION AjKltreb VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: - �
ElI have and will maintain a Certificate of Consent to sell-Insure for Workers Compensation, I I Y Ut 1xUr'Gh I IIVU Building �, e,y�(_
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this '
permit Is Issued. Seismic
I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
_the Labor Code,for the performance of the work for which this permit is Issued.My Worker's - Q
Compensation Insurance carrier and Policy number are: Total
Carrier Policy No. PERMIT AUTHORIZA ION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
,a./s
COMPENSATION INSURANCE N.C.O 'C``!l./'- • ' Z O
(This section need not be completed If the permit Is for one hundred dollars($100)or lase.)
I 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 became subject to the Workers'Compensation Laws of Can. All roofs shall be inspected 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 co with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP
with such provisions or this permit shalnbe 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,end All roof coverings to class" rbetter.
hereby authorize representatives of this city to anter upon the above-mentioned property for in. /�
sp purposes.
IW , '
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
judgments,Coate and expenses which may in any way accrue against said City n consequence /
at 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