R 5063 PERMIT R_ 5063
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1 S DAYS OF PERMIT ISSUANCE OR
• 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
zle RESIDENTIAL COMMERCIAL OTHER
-
OWNERS HAZARDOUS FIRE AREA
A
NAME VES ❑ It yes assembly s required.Class
-/ NO ❑ Inifial I.C.B.O.If
ADDR SS R/G EXISTING ROOF COVERING
PHONE
NUMBER OF EXISTING COVERINGS
CONTRACTO
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS �j///� r E OF ROOF COVERING
CITY&ZIP •'� 1
EXISTING
I
PHONE (O BUILT-UP ROOF
LICENSE / q "
NUMBER ` � ASPHALT SHINGLES NUL¢1 9❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter g(commencing with Section WOOD SHAKES ��J a996
7000)of Division 3 of the Business and Professions Code,and my license is In full farce and
I Vh t
effect. WOOD SHINGLES c C. e,
License Class Lic.Number V
Date Contractor OTHER(SPECIFY) ❑
OWNER-BUILOER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Lew 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 to file a signed statement that he Is licensed pursuant to the provisions
of ins 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
e civil penalty of not more than five hundred dollars($500).): WOOD SHAKES
E]1,as owner of the property,or my employees with wages as their sole compensation,will do
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes-
sions Code: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 El
Improvements are not Intended or offered for sale.It,however,the building or Improvement
Is sold within one year of completion,the owner-bullder will have the burden of proving that he did OTHER(SPECIFY) ❑
not bulld or Improve for purpose of sale.).
❑I,as owner of the property,am 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(a)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 em exempt under Sec. ,S It P.C.for this reason
OwnerDate
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: w
❑1 have and will maintain a Certificate of Consent to self-insure for Workers Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this (T/� g
permit is issued. /(Q' ^ V Seismic
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of II '(/U/1
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
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed If the permit la for one hundred polls re($100)or lase.)
I certify that In the performance of the work for which this permit is upd,t shall not employ
any person In any manner so as to become subject 'the orkera' pensatlon Laws of call. All roofs shall inspected prior to any roofi n g mat being
Tornio. c ( installed. If a roof is installed without first obtaining an
Date Applicant cate y inspection,I agree to remove all new materials for inspection.
NOTICE subject to theOWorrkers'Compensation provisionls of thefiLaborr Code,you mustforthwithcomply Applicant understands and will Comply with all non point
with such provisions or this permit shalGh deemed revoked, source regulations.
I certify that I have read this application and elate that the above Information Is correct,I agree //ppp
to comply with all city and county ordinances and state laws relating to building construction,and All ropt
Verin Isfb be class"C"Or better.
hereby authorize representatives of this city to anter upon the above-mentioned property for In ��
spectlon a purposes. l/OLi
.(We)agree to save,Indemnity and keep harmless the City of Cupertino against Ilabilhlee,
judgments,coats and expenses which may In any way accrue against said City In consequence
• of the granting at this permit. ATUWOF 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