R 5080 PERMIT R_ 5080
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777- 228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
• 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS /
0 {� 44�, #'/' RESIDENTIAL COMMERCIAL OTHER
OWNERS HAZARDOUS FIRE ARE
VES ❑ II yes—I understand that a Class A
NAME 0 0 roof assembly is required.
NO J Initial I.C.B.O.K
ADDRESS U �f . EXISTING ROOF COVERING
PHONE 7 /" NUMBER OF EXISTING COVERINGS
CONTRACTOR'
NAME ,�d TO BE REMOVED TO BE RETAINED
ADDRESS0 Le TYPE OF ROOF COVERING
CITY&ZIPowMIA
l EXISTING
PHONE (/ BUILT-UP ROOF
CENSE
NUMBER M 7S n3f ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter g(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and
elleWOOD SHINGLES
D /yJ
License Class Litt..Number ✓� a>�
Dateten Contractor
OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
1 hereby affirm that am exempt from the a: Any city License Lew for the following reason. Y�
(Sec.7031.5,Business improve and Profeolish.or re Coda: Any dry or county which requires also e permit to
construct,alter,Improve,to file asigned staeny mentrthathe prior to license Issuance,to the
sins BUILT-UP ROOF ❑
applicant for such permit to lila aelgnetlr 9'coemthathe it licensed pursuant tothe provisions the
of the Contractor's license Lew(Chapter a is ex a pt I whh om and 7000)of for the 3 0l the _
•
exemption.
and Perflation f Code)or thet he la exempt therefrom end the beds he me scant to ASPHALT SHINGLES
a civil pen.Any f violation more
of Section 703 hundred
by any s($5 ant for a permit subjects the applicant to
e civil penalty of not mora than flue huntlretl tlollare($500).):
01,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES N�
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Prones-
slons Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES AV v^ ❑
Improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not intended at offered for sale.Il,however.the building or Improvement tYsl tt`
Is sold within one year ofcompletion,the owner-builder will have the burden of proving that he didOTHER(SPECIFY),%,, tge
(SP ❑
not build or Improve for purpose of sale.). ��,%,,
EJ 1,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 coniractor(s)licensed pursuant to the Comractoes License Law, PROVIDE MFGR. INSTALLATION SPECS.
[:]I am exempt under Sec. ,B 8 P.C.for this reason
Owner Date — I
APPLICATION DATE / VALUAT N PERMIT FEE
WORKER'S COMPENSATION DECLARATION
E]I have
affirmunder
attain ay of perjury of Cof thensent
followingdeclaration:o �^ ��
❑ haveand willmaint37a Certificate of Consent tospif-forma for Worker's Compensation, /SII/ BUllding�
as provided for by Section 3700 of the Labor Code,for the performance of the work for which This �S
permit h v and r(fppy/Q/J/ Seismic
❑ have entl will maintain Worker's Compensation the work
which this as required Is
Issued.
d.My 3700's the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's 90-2-L-07-
Compensation
Insurance carrier entl Policy number are: Total
Carrier Policy No. ERMITAUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.I]
(This section need not be completed If the permit is for one hundred dollars($100)err lase.) t`[7J�J6•
I certify that In the performance of the work/or whi h this permit Is Issued,I shall not employ -
fanyom person any manner ee.o become subject m war mpaneanen Laws m cell- roots shall be inspec d prior to any roofing material being
fornfa. _ installed. If a roof is installed without first obtaining an
Date ` Appflcanl inspection,I agree to remove all new materials for inspection.
NO E TO APPLICANT: If,alter making this Certificate of Exemption,you should become
subject to the Workers'Compensation provisions of the Labor Cotle,you must forthwith comply ?PPlicant understands and will Comply with all non point
with such provisions or this permit shall be deemed revoked. source regulations.
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 orcinances and state levee relating to building construction,and All roo overind be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in. ///JJJ
sp(We)agrpoaea. _� 9r��
(We)puree to save,indemnity and keep harmless the City of Cupertino 9aelnet liabilities,
�/ G
judgments,costa and expenses which may In any way accrue against said City n consequence
. of the granting of this permit. SIG AUR 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION ,
OFFICE COPY