R 5194 PERMIT R_ 519 4
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
. 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
a0l FooeR es r A-ke
RESIDENTIAL COMMERCIAL OTHER
OWNER'S ,` HAZARDOUS FIRE AREA
NAME FARM[ 6 L►4 S �L. YES rl yes
assembly s required.
nderstand that a Class A
NO Initial I.C.B.O.N
ADDRESS EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS I
CONTRACTOR'S -
(�ARIbrC ^'VO JF=AC/ Cy TO BE REMOVED TO BE RETAINED
NAME Ips �C
ADDRESS f� w /�
TYPE OF ROOF COY
CITY&ZIP Phy EL a ftJ zA& R-0-Ar .+
I EXISTING
PHONE 409- agta — NOD - BUILT-UP ROOF C3 \
LICENSE ❑ /�
NUMBER ASPHALT SHINGLES
LI=D CONTRACTORS DECLARATION LT /
hereby affirm that amusi nes under erosions of Chapter B(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business entl Professions Code,end my license le In full force end
effect.
WOOD SHINGLES ❑
License Claes Lie.Number
Date Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER 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 the Contractors License Law(Chapter 8(commenclng with Section 7000)of Division 3 of the
Business and Professions Cade)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 cave penalty of not more than five hundred dollars($500).): WOOD SHAKES �I
❑I,as owner of the property,or my employees with wages as their sale compensation,will do
the work,and the structure Is not Intended or offered for tele(Sec.7044,Business and Profee-
slonsCode:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑
Improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for sale.If,however,the bulldIng or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve tot purpose of sale.),
1,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contreclor(e)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
C]I am exempt under Sec, ,B$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;
❑1 have and will maintain a Certificate of Consent to sell-insure for Workers Compensation,
Building
as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which this � � I D , Q'
permit Is Issued. Seismic
❑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 Workers Total
Compensation Insurance carrier and Policy number are: 11 Q
Carrier 41111 C-A NA S E Policy No. PER THORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' /x
COMPENSATION INSURANCE N.CQ CI t UUF1
(This section need not be completed lithe permit le for one hundred dollars($100)or lase.)
I certify that in the performance of the work for which this permit Is Issued.I shell not employ
any parson In any manner so as to become subject to the Workers'Compensallon Laws of Can. All roofs shall be inspected prior to any roofing material being
fornia, installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: if,after making this Certificate of Exemption,you should become Applicant subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP understands and will comply p y with all non point
with such provisions or this permit shell be deemed revoked. Source regulations.
I certify that I have read this application and elate that the above Information Is correct,I agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof c class' "or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In- l�(JJ
spection purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino ocalnat liabilitiesl
judgments,coats and expenses which may In any way accrue against sold City In canesquenca
• of the granting of this permit. 51l NATURE OF APPLICANT DATE l
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