R 5860 APPLICATION FOR CITY OF CUPERTINO
PE
RR- 5860
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
^� BUILDING ADDRESS
I'I o �l wtgFord DFS RESIDENTIAL COMMERCIAL OTHER
OWNERS HAZARDOUS FIRE AREA
PA//11 Ka U YES ❑ If yes-I understand that a Class A
NAME roof assembly is required.
NO K Initial I.C.B.O.M
ADDRESS SA EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS f
CONTRA/g OR'S x
NAME
SSG✓I C-2 �O ` ��✓lg TO BE REMOVED 1 TO BE RETAINED
ADDRESS 212 L i✓tC o( fn R V C TYPE OF ROOF COVERING
CITY&ZIP
EXISTING
PHONE BUILT-UP ROOF
LICENSE S-s--q-13 6 ASPHALT SHINGLES Els/
NUMBER
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Dlvleion 3 of the Business and Professions Code,and my license Is In full force and q
effect. L
G.3 S'Sq 736 WOOD SHINGLES
Eld
' License Clave Lid.Number
Date 3- 31- 99 Contractor f2efngfS3�tv�c¢ N9 OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em 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,after,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 LewCotle(Chapter 9(commencing with Section 7000)of Division 3 of the ASPHALT SHINGLES
Business entl Prolesslone or that he to exempt therefrom and the basis for the alleged Elexemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
s civil penalty of not more than five hundred dollars($500).): ❑
El 1.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 Profes.
alone 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 awn employees,prodded that ❑
such Improvements are not Intended or offered for sale.Il,however,the building or improvement / �'
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ryIOU rel a � 01-1
not build or Improve for purpose of sale.). L�
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct p� '3
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 builds or Improves thereon,and who contracts for such projects
with a contractor a)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.far this reason
Owner Dela APPLICA:I0ATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION 'if
1 hereby aKlrm under penalty of perjury one of the following declaration: /)p
❑I have and will maintain a Certificate of Consent to sail-insure for Worker's Compensation, II{{ll//pR81Buildin
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit le sued, l� Seismic l-
ave and will maintain Workers Compensation Insurance,as required by Section 3700 of C12 OF Sv
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's f'Uf C ILA)
OCompensation Insurance carrier and Policy number are: ��//yU LA Total
Carrier � hd Policy No. PERMIT
PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.I]
(This section need not be completed if the permit Is for one hundred collars(51 00)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 Cell- All roofs Shall inspected prior to any roofing material being
hands' 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: IL after making this Certificate of Exemption,you should become Applicant understands and will cam
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 shell be doomed revoked. source regulations.
I certify that I have reed 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.
spection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, �C` 0,t-4W q„AA-0 3,3
jutl7menta,coats and expenses which may In any way accrue against sold City In consequence
of t a 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