R 5084 PERMIT R. 5084
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERM IT EXPIRATION
REROOF PERMIT (408)777-3225 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
. 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
7 % RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
(!1 fJ YES ❑ If yes-I understand that a Class A
NAME SO,d / O roof assembly Is requires tial I.C.B.O.#
ADDRESS / EXISTING ROOF COVERING
PHONE L` / NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
/� TO BE REMOVED TO BE RETAINED
NAME [�
ADDRESS TYPE OF ROOF COVERING
CITY 8 ZIP— EXISTING
PHONE x��L02 / BUILT-UP ROOF ❑
LICENSE
NUMBER -724T'710 ASPHALT GLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 9(commencing with Section WOOD S K
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect.
WOOD SHINGLES ❑
License Cissa Llc.Number
OTHER(SPE�) E]Date Contractor
OWNER BUILDER DECLARATION PROPOSED 5
hereby affirm that em exempt Ii om the Contractor'°License Law for the uirowing remits,
(Sac.7031.5,Business and demolish,
or rep Code: Any city or county which requires a permit to
construct,alter,improve,d file asigr d statement
ementrthat e,prior foils Issuance,alsorequiresthe BUILT-UP ROOF ❑
eppll<ant for such permit to Ills a signed statement that he Is licensed pursuant to the provisions
of the Contractor'°Llcenae Lew(Chapter 9(commenclnp wlth Section 7000)of Division 3 of the
• Business and Proleasloi Cotle 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
e civil penalty of not more than five hundred dollars($500).):
C]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. r -
sionsCode:The Contractors 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 own employees,provided that ❑
such Improvements are not Intended or offered for sale.If,however,the building or Pmprovament
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) II
not build or Improve for purpose of sale.). R
❑I,as owner of the property,em exclusively contracting with licensed contractors to construct AUG
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 common;for such projects �IIY Uf lrUr'L-Ili u'w
❑ exempt
with a ca m(s) e pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
I em exempt untler Sec. ,B 6 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm untler penalty of perjury one of the following declaration:
❑1 have and will maintain a Camf tate of Consent to sell-maure for Workers Compensation, A/ Bug
1 4�7, (7-�
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this. L� ( Building
permit Is leauetl. /I o VVVV
(DIYwI SBIsm1C /.ev
I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
the Labor Code,for the performance of the work for which this permit is Issued.My Worker's
Compensation Insurance carrier and Policy number are: Total 7 U&•
Carrier Policy No. PERMITAUTHORI TION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NCO
(This section need not be completed If 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 shall not employ
any person In any manner so as to become subject tote Worl rfl�ompensation Laws of Call. All roofs shall be ins cted prior to any roofing material being
°`"10' installed. If a roof is installed without first obtaining an
Date ' s 9d Applicant ^' G inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,atter making this Certificate of Exemption,you should become Applicant understands and will comply
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP p y with all non point
with such provisions or this permit shall be deemed revoked. Source regulations.
1 certify that I have reed this application and state that the above Information is correct.I agree
to comply with all city and county ordinances and state law&relating to building construction,and All roof coverings aclass"C"Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property br Im
ap(W I agrpoeae.
(We)agree to save,Indemnify and keep harmless the City of Cupertino apalnat Ileblililes, � y
judgments,costa and expenses which may In any way accrue against said City 4n consequence JI� TURE A PLICANT DATE
• of the granting of this permit.
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