R 5043 PERMIT R_ 5043
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
• 100 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS nn
�j E AL COMMERCIAL OTHER
ow ER'S . / T //J /�/��t HAZARDOUS FIRE AREA
NAME �> / V e �
YES
rroo,assembly sl requand irtedat a Class A
NO - Initial I.C.B.O.ft
EXISTING ROOF COVERING
PHONE 2 YD NUM ER OF EXISTING COVERINGS
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAME
t
ADDRESS P RO F VE
CITY aZIP_
r EXISTING
PHONEY , BUILT-UP ROOF ❑
LICENSE �/• '"' EDNUMBER ASPHALT SHINGLES
LIED CONTRA TOR DE RATION
I hereby affirm that I am licensed under provisions of Chapter 0(commencing with Section WOOD SHAKES ❑ l�
7000)of Division 3 of the Business and Professions Code,and my license is In lull force and
effect.
WOOD SHINGLES
License Class Lic.Number
Date contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION -'
I hereby affirm that I am exempt from the Contractors License Law for the following reason. PROPOSED
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,altar,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 Contrector'e Llcense Law(Chapter 0(commencing with Sectlon 7000)of Dlvlslon 3 at the EM.
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
a civil penalty of not more than live hundred dollars($500).): ))��
01,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES 1AG 19
�nn ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profile- Ir, J J L
slons Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES 6-
Improves thereon,and who tloes such work himself or through his own employees,provided that I' L ❑
such Improvements are not Intended or offered for eels.ll,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) V❑
not build 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 Corte:The Contractor's License Law does net 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 contractors)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
]1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I 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, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which This /t.�//� Q/,/ n � � g
permit Is issued. !t/D/ /V/ GGJ'!//n /✓`/J/�j/
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of Seismic
the Labor Cotle,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. PERMITAUTHO TION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This Sectlon need not be completed if the permit is for one hundred dollars($100)or leas.)
I certify that In the performance of the work for whi this permit i 'ssuetl, shell not employ
any person in any manner so as to become subject m ork pensation Laws o Caff All roofs S be S Cted prior to any of g m tial b I
fornla. I installed. If a roof is installed without first o tainin9 an
Data 4 Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If, her making this Cartificat of Exemption,you should become
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply Applicant nt understands and will comply with all non point
with such provisions or this permit shal0be deemed invoked, Source regulations.
I certify that I have read this application and stale that the above Information is correct.)agree
to comply with all city and county ordinances and state laws relating to building Construction,and All Vrooin O aclass"C"or better.
hereby authorize representatives of this city to enter upon the above.mentlonso property for In.
spection purposes.
(We)agree to$
ave.indemnify and keep harmless the City of Cupertino against liabilities, �� x
. of me granting of tand his permit, SIGNATURE
which may In any way accrue against said City In consequence SIGNATURE F AFYPL(CANT DA
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 COPV