R 5787 PERMIT R_ 5787
APPLICATION FOR CITY OFCUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 18DAYS PERMIT ISSUANCE OR
WI F DAVE FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
/oiyz
RESIDENTIAL COMMERCIAL OTHER
OWNER' HAZARDOUSFIRE AREA
NAME r �a+Q" VES ❑ r rf — mbly st required. ClassA
NO ❑ Initial I.C.B.O.q
ADDRESS tel — EXISTING ROOF COVERING
PHONE f+ " Zrf NUMBER OF EXISTING COVERINGS
CONTRAC S
f
NAME TO BE REMOVED TO BE RETAINED
ADDRESS yja•"•' 9 gO - TYPE OF ROOF COVERINEXISTINGG
CITYBZIP ff
PHON Svc `}�13��3 7 3 BUILT-UP ROOF ❑ ^
NUMBER 492-700 ASPHALT SHINGLES � ' ®
LICENSED CONTRACTORS DECLARATION [ tUYJ`U
1 hereby affirm that I am licensed under provisions of Chapter 0(commencing with Section WOOD SHAKES 1r�YYYi •alVVV
7000)of Division 3 of the Business and Professions Code,and my license is In full force and
effect. 1,0 WOOD SHINGLES
License Class ✓ 1 Lic.Number 0 - CiTY 4 curthimi)
Data g�149 Contractor _—+ OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am 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,alter,improve,demolish,or repair any structure,prior to Its issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit a file a signedstatement9(commencing
that g it licensed pursuant to the provisions
the
. of the ss an Pro License Lew(Chapter h(commencing with om and 7000)of Division 3 0l the
ex
Business entl Professions f Cotle)or that he a exempt therefrom entl the basso for the alleged ASPHALT SHINGLES
I`yfL-
exemption.Any violationof Section hundred
by any applicant lora permit subjects the applicant to
e civil penalty of not mare than five by employees
dollyeesrs(h wage: WOOD SHAKES❑I,as owner o1 the properly,or to employees wsih wages as their sole compensation,will do ❑
the work,and the structure Is not Intended or offered for Bale(Sec.7044,Business and Profes-
sionCape:The,anwho des such Lewdoes not apply toanowner of property whobuilds idedtor WOOD SHINGLES ❑
Improves thereon,and not does such work himselforthrough his Own employees.or provided that
such Improvements are not Inlentlatl or offered for Bale.It,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 safe.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct ' /
the project(Sec,7044,Business and Professions Code:The Contractors License Law does not PROVIDE LUC.B.O.REPORT NO. 4, Uo 3
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 Lew. PROVIDE MFGR. INSTALLATION SPECS.
[JI am exempt under Sec. ,S&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
_ WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to sell-insure for Workers Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this /� g
per `ielaaaad' 7� /S� 7 � Seismic
ave ted.111 maintain Worker's Compensation Insurance,as required by Section 3700 of. y
„Ih ober Code,for the performance of the work for which this permit is issued.My Workers
Compensation Ina ranee carrier and Policy number are: Total
Carrier FZZ Policy NoS -2f -17`11Z�S PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' ^'
COMPENSATION INSURANCE NA.O
(This section need not be completed If the permit Is for one huntlretl dollars($100)or legs.)
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•Compensation Laws of Cali- 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 Com
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 permlt shalltm 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 rotating to building construction,and All roof coverin s 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, Z
•
judgmants,costs and expenses which may In any way accrue against said City In consequence
of hegrandng of this permit, SIGNATURE OFAPPLICANT DAT
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