R 5901•
OFFICE COPY
APPLICATION FOR CITY OF CUPERTINO NUMBER R— 5901
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
1 BO DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
FJF
JOSef=io4 ��KF�
C
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
VES ❑ If yes — I understand that a Class A
NAME
roof assembly is required.
NO ❑ Inifil I.C.B.O. #
.A
2 // L �RF7T� 4
ADDRESS
EXISTING ROOF /COVERING
NUMBER OF EXISTING COVERINGS L`�r`
14 R
Qt,
PHONE i
*00�TO
CONTRACTOR'S j
NAME
TO BE REMOVED BE RETAINED
ADDRESS
TYPE OF ROOF COVERING
CITY & ZIP
EXISTING
PHONE
BUILT-UP ROOF ❑
_
LICENSE
NUMBER
ASPHALT SHINGLES ❑
y
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em 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 Infull force and
effect.
WOOD SHINGLES ❑
License Class Lie. Number
OTHER (SPECIFY)
Date Contractor
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
PROPOSED
(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 El
for such permit to IIIe a signed statement that he Is licensed pursuant to the provisions
of the Contractors License Law (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
e civil penalty of not more than five hundred dollars ($500).):
❑1, 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 Profes-
sions Code: The Contractors 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 owner -builder will have the burden of proving that he did
OTHER(SP oEl
build or Improve for purpose of sale.).
1,
JJ a
C] 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 LC.B.46REPORT 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.
❑ 1 am exempt under See. B P. ,& C. for this reason
PROVIDE Ml IN�LATION SPECS.
Owner Date
APPLICATION DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑ I have and will maintain a Certificate of Consent to sell -insure for Worker's Compensation,
BUllding�
asprovidedIs for by Section 3700 of the Labor Code, for the pedarmencaof the work for which this
permit is ls6uatl.
b
4 7
❑ have and will Worker's Compensation Insurance, as required by Section
the Labor for 's
D
�
Seismic len
.thethe p
the performance the wokfor
of the work for which this permit Is leauetl. My Worker's
tiOde, Worker's
Insurance Polley
I
Total 16 8,2_0
arormand
terrier and number are:
Carrier Policy No.
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed If the permit Is for one hundred dollars ($100) or less.)
CD
I certify that In the performance of the work for which this permit is Issued, I shell not employ
All roofs shall be inspected prior t0 any roofing material being
any person in any manner so as to become subject to the Workers' CompensaLaws of call-
gon
forma'
installed. If a roofis 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
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
Applicant understands and will comply with all non point
PP P Y p
with such provisions or this permit sha ff be 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 better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes.
(We) agree to ends, keep harmless Clry Cupertino
'� n t
l_IYwn44!__ r�L�
9—An
peIndemnify esw and the of against n liabilities,
judgments, costa and expenses which may In any way accrue against seltl Clry In consequence
OY
SIG TUR OF APPLICANT DATE
of the granting of this permit.
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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY