R 5948 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER Ras 5948
REROOF PERMI INSPECTION DIVISION PERMIT EXPIRATION
*2((408)
�(-/, 2(408)Q 777-.3228 PERMIT EXPIRES IF WORK IS NOT STARTED
„O (_ WITHIN 180 DAYS OF PERMIT ISSUANCE OR
u! cr 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS J
10, �f RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
—[+ /n O YES ❑ If yes—I understand that a Class A
NAM��I.Q1YLl-[yam,$ [f [ (L/7 I' ///)D ` roof assembly is required.
—7 / NO Initial I.C.B.O.k
ADDRESS- /27 �. n 1 V2NS I�� %O o EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTO 'S 1 c.
NAME La.S G-4,/ O J / d O 7 /1 - //'�,� TO BE REMOVED TO BE RETAINED
CITY&ADDRE2 P — & &0,4 02 C, 4s Crtt,?oS iV 0 / TYPE OF ROOF COVERING
IT
PHONE BUILT-UP ROOF El
LICENSE 9s3
' NUMBER /J Y(p ASPHALT SHINGLES ❑.
LICENSED CONTRACTORS DECLARATION
hereby affirm that I am licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES /\�-^•
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
alias. WOOD SHINGLES ❑
License Class C4- 5 9 Le.Number 1"
DateOWNER-BUILDER
OTHER(SPECIFY) 0
OWNER-theConRDECL License
PROPOSED / ��
hereby affirm that 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
00
of the ss an Pro License Lew(Chapter S(commencing with Section 7000)of Division 3 of the00 or
exemption.
and violation of Code)or that he le exempt therefrom and the subject
for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit aublecta the applicant to
basil
e civil penalty of not more than five hundred doll am($500)J:
❑I.as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Proms-
, slons Code:The Contractor's 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 WOOD SHINGLES
such Improvements are not intended or offered for sale.If,however,the building or Improvement
Is sold within one year of completion,the wner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for 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 Contractors 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 contractors)licensed pursuant to the Contractor's License Law.
❑I am exempt under Sec. ,B&P.C.for this reason PROVIDE MFGR.INSTALLATION SPECS.
OwnerDate
WORKER'S COMPENSATION DECLARATION APPLICLDMDATIE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:❑1 have antl will maintain a Certificate of Consent to sal4lnsure for Worker's Compensation,as provitletl for by Section 3700 of the Labor Code,for the performance of the work for which this ��npry Ipermit Is Issued. WfJ U❑1 have antl will maintain Worker's Compensation Insurance,as requiretl by Section 3700 of I
the Labor Co e,for thepadormeno. the w rk fo which this permit la Issued.My Worker's TVCompeneal Insurancecarrler an Icy CIT 1 .. Total
Carrie (to o ORIZATION DATE
CERTIFICATE OF EXEMPTION Ff10RKERS' _
COMPENSATION INSURANCE N.C.]
(This section need not be completed If the permit Is for one hundred dollars($100)or lees.)
I certify that in the performance of the work for which this permit Is issued,16hall not employ
rornla.
any person In any manner so as m become subject to me workers compenseuon Laws of can- All roofs shall be inspected prior to any roofing m terial being
- installed. If a roof is installed without first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It,after making this Certificate of Exemption,you should become Applicant understands and will with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP Comply p y
with such provisions or this permit shall be deemed revoked, source regulations.
I certify that I have read this application and stare 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 cover' , to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
jutlgmente,coats antl..'pensee which may In any way accrue against said City In consequence DATE
or the granting of this permit. SIGNATURE OF APPMA19lV
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. - DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. Ic DATE Z INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
__ OFFICE COPY _ ___