R 5308 APPLICATION FOR clTv of cuPERTwo
NUMBIERR- 5308
REROOF PERMIT INSPECTION DIVISION - PERMIT EXPIRATION .
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1B0 DAYS OF PERMIT ISSUANCE OR
WI180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
60711P I veii,7XM n
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
'4r ChD� VES ❑ If yes s I understand that. Class A
NAME ' r rA.= llL roof assembly is required.
NO Initial I,C.B.O.q
ADDRESS- �-0
t j U EXISTING ROOF COVERING
PHONE DO ' NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME � YGI'v�+ TO BE REMOVED TO BE RETAiNy,6
ADDRESS TYPE I Ro6F
CITY&ZIP
r EXISTING
PHONE BUILT-UP ROOF
LICENSE
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license is In lull force and
effect.
WOOD SHINGLES
License Class Lin.Number '
DareContractor
OTHER(SPECIFY)
OWNER BUILDER DECLARATION PROPOSED
hereby affirm that am exempt from the Contractor's License Lew for the requires
a remits.
(Sac.7037,5,r,Improve,
and Professions p Code: Any city or county which requires a permit to
applicant
alrer,Improve,to file demolish, n repairany structure,e,prior lope Issuance,pursuant also theprovirequires the ns BUILT UP ROOF ❑
applicant for each permit a flaw a signed(Chapter 9(comnt that la le Ilceneetl pursuant to the pro 0(the
of the ss and tPro Llcenae Law)orthat B Is ex enclnp with Section 7000)of for the
3 al the
ex
Business entl Professions f Code)or that he le exempt therefrom and the basis for the applicant
to ASPHALT SHINGLES
exemption.Anyviolationo t more
of Section 7031.$by any applicant for a permit subjects the appllcenl to
e civil penalty of not more Ihan flue hundred dollars($500).):
❑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 Proles-
' saono Code;The Contractor's License Law does not apply to an owner of property who bullas 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 onto.It,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) E]'
not build or Improve for purpose of sale.).
❑f,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Profsssinns 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 contractor(o)licensed pursuant to the Contractors License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑I em exempt under Sec. ,B&P. .for thl reason
d47 5;
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following decreraeon: w
01 have and will maintain a Certificate of Consent to self-insure for Workers Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit la Issued,
Ps q Seismic
❑ have entl will maithe performance
Worker's Compensation the wokfor Insurance,as requiredsu Sectiod.My
Workers s W
the Labor Cada,for the pertormand of the work for which this permit is leauetl.My Workers ��MV/s Total
Compensation Insurance carrier entl Policy number era; {/ `��
Carrier Policy No. P THORIZATION DATE
` CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O L 1
(This section need not be completed If the permit Is for one hundred dollars($100)or leas.)
4" I certify that In the pertormence of the work for which this permit Is Issued,I shell not employ
-� any person In any manner an as to become subject to the Workers'Compensation Laws of Cell- All roofs shall U15 Inspected prior to any roofing material being
forma. 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: If,after making this Certificate of Exemption,you should become
subject to the Workers'Compensation provisions of the Labor Code,you moat forthwith comply Applicant understands and will comply with all non point
with such provisions have
rad permit shall application aeemee that the source regulations.
certify met have rndc Thistyordinances
state thattheabove Information tobuilding
uilinn Incorrect. agree
tocomply with all city and county ordinances ane sterelaws hela oto entingconstruction,entl All roof coveriggs to be class"C"or bolter. -
herebyauthorize representatives of This city to enter upon the ebovementlonatl property for In.
spectres
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
f the judgments,costs and
e granting of this permit.ee which may In any way accrue against said City In consequence SIGN URE OF APPLICANT DXrE
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