R 5153 PERMIT R_ 5153
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (40$)777-922$ PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
1 B DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESSS (�
/.oJ 11 �� ��J RESIDENTIAL :� COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
NAMEi*T C // /V S��yC YES ❑ Ayes—I understand Mate Class A
55ernbly l5 requited.
- NO _ Inroal LC.B.O.M
ADDRESS ���G EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS /
CONTRACTOR'/S�•1
70 BE RETAINED
NAME C.. TO eE REMOVED v
ADDRESS /' TYPE OF ROOF COVERING
CITY 8 ZIP EXISTING
PHONE Lia— era�,—� 1�,.r�! BUILT-UP ROOF ❑
LICENSE 369 Z. ASPHALT SHINGLES
NUMBER ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em 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
effect.
9�3 369I WOOD SHINGLES ❑
License Ctas Llc.Number
Dote q Contra far e OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law 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 Lew(Chapter g(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 ❑
exemption.Any violation of Section 7031,5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($501
❑l,as owner of the property,or my employees with wages as their solo compensation,will do WOOD SHAKES
the work,and the structure Is not Intended or offered for sate(Sec.7044,Business and Proles
cions 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.II,however,the building or improvement
Is sold within one year of completion,the cwnerbullder 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 Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
have and will maintain a Certificate of Consent to selMnsure for Worker's Compensation, ` BUIIdIn� 1
e pro ed for by Section 3700 of the Labor Code,for the performance of the work for which this �QQ J�
rl
permit Is Issued. s elo Seismic 77 40
❑ have antl wool the Performance
Workers f the w rk for Insurance,ee required by Sachin 3700's A
the Labor Cotle,for the penormanda of the work for whish this permit Is Issued.My Worker's %r1`
Compensation�Insurance terrier and Policy number are: I l 2, Total
Carrier`-z �TE ��NL Policy No, –e6 !`PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.I]
(This aectlon 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 I shall not employ
any person In any manner so as to became subject to the Workers'Componsatmn Laws of Call- All roofs shall be inspected p►lorto any roofing material being
foals. installed. If a roof is installed without first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
NOTICE
subject to the OWor ere'Compefne,after tion provisions ofthis thelLaborr Code,of °yolu mustuforthwlithbcomplyecome Applicant understands and will comply with all non point
L with such provisions or INS permit shalgbe deemed revoked. source regulations.
I certify that 1 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 b CI S"C'or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes.
(We)agree to save,Indemnity,and keep harmless the City of Cupemno against liabilities, 6
judgments,costs and expenses which may In any way accrue against said City in consequence
• of the granting of this permit. NATO F APPLICAN DATLF
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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