R 5093 PERMIT R_ 5093
APPLICATION FOR CITY OF CUPERTINO NUMBER
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.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNE HAZARDOUS FIRE AREA
l / !� YES ❑ If yes—I understand that a Class A
NA G!�0 ! mof assembly is required
Q/ NO Initial I.C.B.O.H
ADDR s I�S82 4t'SRHi2i /CAGY. EXISTING ROOF COVERING
PHONE 6^ 1098^ NUMBER OF EXISTIN COVERINGS
CONTR TO
NAM TO BE REMOVED TO BE RETAINED
ADDRESS 4E OF ROOF COVERING
CITY&ZIP
EXISTING
PHONE BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION ❑ �/
1 hereby affirm that I am licensed under provisions of Chapter S(commencing with Section WOOD SHAKES y
7000)of Division 3 of the Business and Professions Code,and my license Is In full force andeff !V/
License
r(� / yncy WOOD SHINGLES ❑ ��
Llcen$e Cleae 3.� Lie,Number 6! J
Dela Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Lew for the following reason.
(See.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 lesuance,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 Law(Chapter B(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($500).):
[3 1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES El
the work,and the structure Is not Intended or offered for tele(Sec.7044,Business and Profes•
dons Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES
Improve$thereon,and who does such work himself or through his own employees,provided that ❑ (ys.
such Improvements are not Intended or offered for seta.If,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)
not build or Improve for purpose of sale.). -
❑I,as owner of the property,em exclusively contracting with 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 builds or Improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
[21 am exempt under Sac. ,B 5 P.C.for this reason
Owner Defo
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 at the
of Consent to ePerInsure for Workers o Compensation, AUG q 1 199 BUIIdir �!
pe provided for by Saetlon 37000lthe Labor Coda,for the performance of the work for which ihla H (J g
Parrott Is haee and seismic v
❑ have end w111 the performance
Worker's Compensation which this as required by Section 37ke 0l
the Labor Code,for the perfarmence of the work for which this per Is laeuetl. Workefe I,1 I I Vi k:LII'yt i I Ila) �Q ♦A..t
Compensation Insurance carrier entl Policy number are: (�J Total
�Carrial `� 666M Icy Na. PERMIT AUTHOR ION DATE
4,s�),vxs.:k, CERTIFICATE OF EXEMPTION FROM WORKERS'
vr COMPENSATION INSURANCE N.C.O
(This section ne not be completed It the permit Is for one hundred dollars($100)or lees.)
I certify that In the performance of the work for which this permit Is issued I shell not employ
any person In any manner so as to become subject to the Workers'Compenaetlon Laws of Cell. 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: IL after making this Certificate of Exemption,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensation pprovislons of the Labor Code,you must forthwith comply pP p y p
with such provisions or this permit shal.be deemed revoked. Source regulations.
I certify that I have read 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 cOnstrucdOn.entl All Of COVefin to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
epWo purposes.
( e
(We)agree tos save,expenses
and keep harmless the City of Cupertino apalnet liabilities,
ence
Judggments,costa and expanses which may In any way accrue against said City In consequence
of 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 rnpv