R 5243 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBERR_ 5.2 4.3
INSPECTION DIVISIONPERMIT EXPIRATION __J
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
•
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
WI180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS / ,/)ev 10 �/,�,f
Q ily,(Q
RESIDENTIAL COMMERCIAL OTHER
Ow ER's HAZARDOUS FIRE AREA
NAME ,d/y�a� VES .❑ If yesss assembly
is required. Clam A
If assembly is required.
NO � Initial LC.B.O.#
ADDREss��a 7 �� �l/�ri1'� y� EXISTING ROOF COVERING
PHONE _Z yZG� NUMBER OF EXISTING COVERINGS _
CONTRACTOR'S`
NAME d(yk'/A�////4�� TO BE REMOVED TO BE RETAINED
Ci CITYADDRESSB ZP S71 /%'/��'/�' .S�
EXISTING f"'r'"'^
PHONE ,2 7J;)- /37 L� BUILT-UP ROOF ❑
s NIUMBER O ASPHALTSHINGLES'
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter B(commencing with Section WOOD SHAKES ❑
7000)of DIVinlon 3 of the Business and Professions Code,and my license Is in full force and
effect. WOOD SHINGLES
ElLicense Claes LIC.Number
Date Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
1 hereby affirm that I am exempt from the Contractors License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,miter,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 Contractor's License Lew(Chapter S(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 ASPHALT SHINGLES v1
exemption.Any vlolation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500).): D SHAKES S I,as owner of the property,or my employees with wages as their sole compensation,will do ❑
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Prefee.
alone Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,provided that ❑
such Improvements are not Intended or offered for sale.If,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contractingg with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O. REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractors)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
C]I em exempt under See. ,B$P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION 4PRWIIQATION DATE VALUATION PERMIT FEE
I hereby affirm under penally of perjury one of the following declaration:
❑1 have and will mal a of the
r Consent to sell for Worker's Compensation, •_ ��� // w �r� Building
as provided for dyillma 3700 of the Leber Consentode,for to sel for of Wtheworkforwhich ensation $VN �!� g
permit Is Issued. Seismic
R-O--
❑1 have and will maintain Workers Compensation Insurance,as required by Section 37000 -
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker�1TY 3r CUPEH I INO
Compensation Insurance terrier and Policy number are: Total
1 Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.] /A
(This section need not be Completed If the permit le for one hundred dollars($100)or lees.) lV/1
1 certify that in the performance of the work for which this permit Is Issued.I shall not amtoy -
any person In any manner so as to become subject to the Workers'Compensation Laws of Ban. All roofn shall be inspected prior to any roofing material being
fornix' y/ � � �/ installed. If a roof is installed without first obtaining an
Date//_" '/ Applicant � q .�( inspection,I agree to remove all new materials for inspection.
ecome
subject NOTICE thee Worrkers'Compensate n pro0slons of the Labor Code,s Certificate of Exemption,
mustufo thwlithbcomply Applicant understands and will comply with all non point
with such provisions or this permit shallrbe 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 ordinances and state laws relating to building construction,and All roof coverings to be class"C"Or beffer.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
ape We)agree to r�/
(We)agree s save,expenses
and keep harmless wa cc City ai Cupertino City
Con liabilities, fj
judgments,Date and expenses which may In any way accrue against said City In eonaequence
of the granting of this permit. SIISINATUREAF 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
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