R 5898 APPLICATION FOR CITY of CUPERTINO PERMIT
R R- 5898
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.
BUILDINGADDRESS
ZV EUll Ciatcr RESIDENTIAL COMMERCIAL OTHER
OWNER'S /� ��/ � (� J/�((�� HAZARDOUS FIRE AREA
NAME F� ! Z, �, 1�1, L( '��g YES ❑ IIyess Iunderstandthat, ClassA
�r` roof assembly is required
�( f NO ❑ Initlal I.C.B.O.tt
ADDRESS ,��J �' L�•Y " 1 L �(�tJ(i'�'- EXISTING ROOF
�yrCOVERING
PHONE NUMBER OF EXISTING COVERINGS �.fa•
CONTRAC R'S
�I\ sTO BE REMOVED_TO BE RETAINED
NAME_
ADDR �� ����� /�.�a�.� TYPE OF ROOF COVERING
CITY&ZIP 6 6 �-i�l !7
EXISTING
PHONE ��/ 7 BUILT-UP ROOF ❑
LICENSE
NUMBER •-Z., ASPHALT SHINGLES
UKJt,N5hU GONTRACTORS DECLARATION
hereby affirm that I em licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license is In full force and
effect. ite WOOD SHINGLES El Class V Lla Number •
Data contractor OTHER(SPECIFY) El
NER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Conbactols License Law for Ne 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 El
for such permit to file a signed statement that he is licensed pursuant to the provislone
of the contractor's License Lew(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 SHINGLES
exemption.Any violation of Section 7031.5 by any applicant fora permit subjects the applicant to
e civil penalty of not more than five hundred dollars($500).):
01,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 sale(Sec.7044,Business and bPrpips-p I p�
Ione Code:The Contractor's License Law does not apply to an owner of property who all o. D WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,provided that E]
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 burden of proving tbOt�pLdllAC psIS�THER(SPECIFY) ❑
not build or Improve for purpose of sale.). GSL�I�d ((..Ir OJ I11V
❑I,as owner of the property,am exclusively contracting wllh 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 bullds or improves thereon,antl who contracts for.such projects.-
with a contractor(s)licensed pursuant to the Contractor's License Lew. PROVIDE MFG R.INSTALLATION SPECS.
El am exempt under Sec. ,S B P.C.for 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: Q 0
I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, Buildingas provided for by Section 3700 of the Labor Code,for the performance of the work lar which this / n
permit is Issued. (/O YS p
❑1 have and will maintain Worker's Compeneatlen Insurance,as raqulretl by Section 3700 of f _ Seismic ---I?
the Labor Cotle,far the performance of the work for which this permit Is lsauetl,My Workersompor
Carrier on Insure�Trier and Policy nu�mbe (y�) / Total 7
80
Carrier ATE F rz/�Ypr"" 77YY ROMW R ]_ PERMITAUTHORIZATION DATE
CERTIFICATE EN EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not r completed if the permit Is for one hundred dollars($100)or lose.) J D R III,
pertly that In the performance of the work for which this permit Is Issued, shell not employ L "l
any person In any manner so as to become subject to the Workers'Co penaatlon Law.,of coli- All roofs shall be inspected prior to any roofing material b ing-
lornia. , installed. If a roof is installed without first obtaining an
Date «i Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: II,after mak i s Carli tate of Exe ptlo�Ihouldb....M.m. q licant understands and will tomsubject to the Workers'Compensation pro ons of the Labor Code, PP ply with all non point
with such provisions or this permit shell be deemed revoked. Source regulations.
I certify that I have read this application and slate that the above information If Correct I agree
to comply with all city and county ordinances and State laws relating to building construction,and All roof coverings tob lass"Ca or jl:, �
hereby authorize representatives of this city to enter upon the above-mentioned property for in. C
spection purposes.
(We)agree to save,indemnity and keep harmless the City of Cupertino agfinal liabilities,
judgments,costs and expenses which may In any way accrue against said City o consequence
of the granting of this permit. A URE OF APPLICANT DATE
PRE-INSPECTION: -PLYWOOD: IN- SS:
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