R-5349 APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 5349
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM IAST CALLED INSPECTION,
BUILDING ADDRESS /^//
ESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
NAME r! C - YES ❑ If yes—1 understand that a Class A
roof assembly is required.
NO Initial • I.C.B.O.k
ADDRERR -�`"�((N� •����� y-/f EXISTING ROOF COVERING
PHONE — NUMBER OF EXISTING COVERINGS
CONTRACTOR'S TO BE REMOVED TO BE RETAINED
NAME TYPE OF ROOF COVERING
ADDRESS
CITY&ZP �?2-q /✓�6�/�l�J�� l/' -
EXISTING
PHONE ( Y � 1 � BUILT-UP ROOF ❑
LICENSE ��r..- 7? ASPHALT SHINGLES ❑
NUMBER
LICENSdunder r Csi DECLARATION
hereby affirm that em Business
consed under Professions
ions of Chapter a(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business end ProfesslOns Code,and my license Is In lull force and
effect _ f Z WOOD SHINGLES
License Class Lic.Number l ❑
OTHER(SPECIFY) 1�
Date Contractor
Nom BUILDER DECLARAT PROPOSED �Z
hereby affirm that am exempt from the Conbactors LI se Lew for the following reason.
(Seo.7031.5,Business and Professions Code: Any city county which requires a permit to
construct,alter,Improve,demolish.or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF ❑ D
applicant for such permit to Ills a signed statement that he Is licensed pursuant to the provisions r
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 re
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($500).):
C]1,as owner of the property,or my employees with wages as WOOD SHAKES their sole compensation,will do ❑
the work,and the structure Is not intended or offered for Sala(Sac.7044,Business and Profes.
dons Code:The Contractors 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
much Improvements are not Intended or offered for sale.If,however,the bullding or Improvement
Is sold within one year of compilation,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 contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions 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(s)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
O 1 am exempt under Sec. .B&P.C.for this reason
Owner Data Ap @I T 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 Workers Compensation, �� o Building
as provided for by Seaton 3700 of the Labor Code,for the performance of the work for which thls ❑❑�r�
permit Is Issued. q[rj� � ^D r `'� $eISmIC
❑ have and will maintain Worker's Compensation Insurance.as required by Section 3700 of CF// (f
.the Labor Code r/the pe0 rmance the work for w ch this permit is Issued.My Worker'scff W sur Hr� Total
CompensatI ne once rend y number er ,(/�In/{ /
Carrier L POIICy No.V" -��/ PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.p ���
(Thio section need not be completed If theforPermit Is for one hundred sued,dollarsI(51 00)or lase.)
certify that in the performance of the work for which this permit Is msued shall not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Cali. All roofs shall be inspected4witrr to any roofing material being
fornia, installed. If a roof is 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 A 11 n understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP P Y P
with such provisions or this permit shall deemed revoked. SO Ce re ulalio
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 roof Ver S be class' or betteADUA-Tv
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 Cupertino against liabilities,judgments,costs end expenses which may In any way accrue against said City In consequence
of the granting al his permit. SIGN U OFAPP ICAN
. 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 _