R 5168 PERMIT R_ 516 8
APPLICATION FOR CITY OF CUPERTINO . NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
1 WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUIL DING ADOREES/SS �/�J
RESIDENTIAL__[___COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME �L1 roof assembly is required.
❑ Initial I.C.B.O.M
� ADDRESS w/, "`-� � NO EXISTING ROOF COVERING
PHONE c�,5 2— :2— Z
NUMBER OF EXISTING COVERINGS
r' CONTRACTO '
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP
i ,5 /2s EXISTING
L/
PHONE 7 -7 — 2 BUILT-UP ROOF PAIDLICENSE ❑
NUMBER S73 (V ASPHALT SHINGLECC'T I aD 1996
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES CITY U11- WrC .- i�V
effect.
7000)of Division 3 of the Business and Professions Code,and my license is In lull force and
C d� WOOD SHINGLES ❑
License Class v � I Lie Number
Dale �O f5 CIL Contractor iCAtGA OTHER (SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Lew for the following reason. jl
(Sec.7031.5,Business and Professions Coda: 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 ❑ j
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions /7
of the Contractors License Lew(Chapter B(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 Seoion 7031.5 by any appplicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollare(S500j.):
❑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.
I Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES E3Improves 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 contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Lew 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.
C]I am exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
El I have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, BUI
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this /
permit issued. /�11 /� 70 $eIS 11
have entl will maintain Workers Compensetlon Insurance,ea raqulretl by Section 3700 0l /v /S/ /
th a or Code,for the performance of the work for which this permit Is Issued.My Worker's
Compensation In nce srrieran Policy number are: Total
Cerner �CL"Ld— Policy No.95-5--1 _13Z2 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.E)
(This section 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 shell not am joy
any person In any manner so as to became subject to the Workers'Compensation Laws of Cali- All roofs shall be inspected prior to any roofing material being
fornix. installed. If a roof is installed without first obtaining an
Date Applicant inspection,1 agree to remove all new materials for inspection.
NOT CE TO subject t.the Workers'Compensation provisions ofthtelLabor Code,yocate of iu must fothwllthc mora Applicant understands and will comply with all non point
with such provisions or this permit shall deemed revoked. y py 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 Zroofcfin be cla or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spectionpurposes. la//�-/L 6
(We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costa and expenses which may In any way accrue against said Clty In consequence
• of the granting of this permit. SIGNATUR F 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
OFFICE COPY