R 5988E
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OFFICE COPY
PERMIT R_
5 9
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
(„�
RESIDENTIAL9. COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
V i '� Sh e (r
YES ❑ Il- I Understand that a Class A
NAME— 1 �i
root assembly is require d
.NO ❑ Initial I.C.B.O.R
•
_ l
�— �StCr, S
EXISTING ROOF COVERING
ADDRESS 1
PHONE g 3S — LAS
NUMBER OF EXISTING COVERINGS d✓ �•
CONTRACTOR
NAME
O� n
TO BE REMOVED TO BE RETAINED
ADDRESS +1-�!`x•�,� _/� (�.�_
Cev)nec_A 1
TYPE OF ROOF COVERING
CITY&ZIP ryr� If- 11 •
EXISTING
r , C_."qZ/S-_4/C_
PHONE LEO) � �A —�jl 9 �
BUILT-UP ROOF
LICENSE NUMBER a /4-a4
ASPHALT SHINGLES
WOOD SHAKES
LICENSED
underCONTRACTORSsof Chapter 9 (N
I hereby affirm that em Ilcanaad under previsions of Chapter B (commancinp with Section
with
7000) of Division 3 of the Business and Professions Cotle, antl my license le In force entl
deem. C _•-'3a�a�•
�
WOOD SHINGLES ❑
License Class Llc. Number
Date I7� Contractor�� rY� F%_
OTHER (SPECIFY) ❑ �_
OWNER-BUILDER DECLARATION
R&
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
PROPOSED
(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 Contractora License Law (Chapter 8 (commencing with Section 7000) of Division 3 of the
ID A 8 FN
Business and Professions Code) or that he Is exempt therefrom and the ball, for the alleged
ASPHALT SHINGLES
exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of not more than five hundred dollars ($500).):
❑1,a, owner of the property or my employees with wages as that, sole compensation, will do
WOOD SHAKE 3O
��� ���
the work, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Profes-
sions Code: The Contractor, License Law does not apply to an owner of property who builds or
improves thereon, and who does such work himself or through his own employees, provided that
WOOD SHINC��ES
such Improvements are not Intended or offered for sale. If, however, the bulltling or Improvement
-
Issoldwithinoneyearofcompletion,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, am exclusively contracting with licensed contractors to construct
'
the project (See. 7044, Business and Professions Code: The Contractors License Lew 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 contrsctm(s) licensed pursuant to the Contractors License Lew.
❑ 1 am exempt under Sec. ,B 8 P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner Data
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION
PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
'
❑ 1 have and will maintain a Certificate of Consent to sell -insure for workers Compensation,
as provided for by Section 3700 of the Labor Code, for the PBdDfinence of the work for which INS
BUldln g
permit Is Issued.O/.J�
❑ 1 have and w111 maintain Worker's Compensation Insurance, as requiredsu Section 3700's
seismic , 90
the wokfor
the Labor Code, for the performance of the work for which this permit la Issued. My Worker's
Policy
\1C
Ci.IJ
Compen^satLio,n� I �sursnce terrier and nu ber are:
Total
Carriers ] • �YY f'rl�{ � Policy No.
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
11
v -�
z Q
���CCCJJJ
COMPENSATION INSURANCE N.C.I]
(This section need not be completed If the permit Is for one hundred dollars ($100) or lase.)O
I certify that in the performance of the work for which this Permit I$ Issued, I shall not am toy
any person In any manner so as to become subject to the Workers' Compensation Laws of Cml-
All roofs shall be inspected prior to any roofing material being
fornix.
installed. If a roof is installed without first obtaining an
Data[F �G k Applicant
inspection, I agree to remove all new materials for inspection.
NOTIC TO APPLICANT: If, after making this Certificate of Exemption, you should become
subject to the Workers' Compensation provisions of the Labor Cotle, you must forthwith comply
Applicant understands and will comply with all non point
PP P Y p
with such provision, or this permit shall be deemed revoked.
Source regulations.
I certify that I have read this application and state that the above Informatlon Is correct. I agree
to comply laws to building construction, and
All roof coverings to be class or better.
with all city and county ordinances and state relating
hereby authorize representatives of this city to enter upon the above-mentioned property for In..
spectlon purposes,
/
(We) agree to save, Indemnity and keep harmless the City of Cupertino against liabilities,
Q���/ ?V0
judgments, costa and expenses which may in any way accrue against said City In consequence
of the granting of this permit.
SIGNATURE
URE OF APPLICANT DATE
PREANSPECTION:
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