R 5761APPLICATION FOR
REROOF PERMIT
CITY OF CUPERTINO
INSPECTION DIVISION
(408) 777.3228
[ 0a 3-0 Jo, rook;
OWNER'S
r
NAME�rv,e��c
ADDRESS -/001's v R�AIVl
ADDRESS v
anszlP ((3 SY mo1�A ice�/a V e- 5-
PHONE _[U4)- au
I hereby affirm that I am flconsed under provisions of Chapter 0 (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license is In lull force and
effect. Q /f
License Class / Uc. Number --64-
w,Date (per �q� Can iraclor
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Low for the folbwing 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
applicant for such permit to lila a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Law (Chapter g (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
exemption. Any violation of Section 7031.5 by any applicant for o permit subjects the applicant to
e civil penalty of not more than five hundred dollars ($500).):
❑ I, 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
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 bulltling or Improvement
Is sold within one year of completion, the owner -builder will have the burden of proving that he did
not build or Improve for purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct
the project (Sac. 7044, Business and Professions Code: The Contractors License Law does not
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.
❑ 1 am exempt under Sec. ,B $ P. C. for this reason
owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declaration:
❑ I have and will maintain a Certificate of Consent to self -Insure for Worker's Compensation,
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
perm)fff la lsauetl.
�fl have end will maintain Warkere Compensetlon Insurance, es required by Secllon 3700 0l
Ih/Labor Code, for the penormance of the work for which this permit Is lasued. My Worker's
Compena�et on Ijp�aurence car/��jer antl Policy number are: fo p.
Cerrler'�A^"'v� Policy No. �y S���a
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed It the permit Is for one hundred dollars ($100) or lose.)
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 to the Workers' Compensation Laws of Cell.
fornla.
Date Applicant
NOTICE TO APPLICANT: II, after making this Certificate of Exemption, you should become
Subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
with such provisions or this permit shalr;be deemed revoked.
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 relating to building construction, and
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes.
(We) agree to save, Indemnity and keep harmless the City of Cupertino against liabilities,
judgments, costs and expenses which may In any way accrue against Said City In consequence
PRE -INSPECTION: I PLYWOOD:
TEAR OFF INSPECTION:
RESIDENTIAL r "
PER
NUMBER R- 5761
PERMIT
WITHIN
OTHER
YES ❑ If yes - I understand that a Class A
root assembly is required.
NO � Inihel LC.B.O. k
NUMBER OF EXISTING COVERINGS 61)e_
TO BE REMOVED /2 TO BE RETAINED
TYPE OF ROOF COVERING .
EXISTING
BUILT-UP ROOF
ASPHALTSHINGLES ❑ Z��
WOOD SHAKES C�
WOOD SHINGLES
❑
OTHER (SPECIFY)
PROPOSED
p
BUILT-UP ROOF
❑
ASPHALT SHINGLES
.
WOOD SHAKES
❑
WOOD SHINGLES
❑
OTHER (SPECIFY)
❑
PROVIDE I.C.B.O. REPORT NO.
PROVIDE MFGR. INSTALLATION SPECS.
APPLIGATIqNDATE
VALUATION
PERMIT FEE
JUN 1 AR
Is
Buildin
Seismic U�__Lo
ITY Uf UUrcn f im.
Total
PERMITAUTHORI
TION�w
DATE
V
Nn roars snag oe Inspectea prior to any rooting material being
installed. If a roof is installed without first obtaining an
inspection, I agree to remove all new materials for inspection.
Applicant understands and will comply with all non point
source regulations.
All ro f cover. gs to be class "C' or better.
;A II ���7Y
SIGNA E PLICANT DATE
FINAL:
INSP. DATE !NSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY