R 5881 Jr '
' PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 5 8 81
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
abG—CJ U LVL RESIDENTIAL COMMERCIAL OTHER
-
OWNER'S
o HAZARDOUS FIRE AREA
1 a,Ll.f .r ,W1 YES LlIf yes—1 understand that a Class A
NAME t s f V� 1 'f ` roof assembly is required.
' `� NO Inmal I,C.B4O.q
ADDRESS ` O �G� LL �—t I� EXISTING ROOFCtOVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S � �� � r TOBE REMOVED
NAME / 1A V"X TO BE RETAINED
CADDRESS n Q I 1 / c TYPE OF ROOF COVERING
Q q L EXISTING
PHONE _I -- (� BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED dunderCONTRACTORSsof Chapter 9(N
hereby Daffirmivision
that I am Business
licensed under Professions
of Chapter B(commencing with Section WOOD SHAKES
7000)of Divlelon 3 of the Business entl Prolesslona Code,and my Ilenae s In lull force and effect, � WOOD SHINGLES ❑
License Class !(0 Lip.Number
Date Contractor
OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from the Contractors License Law for the fallowing reason.
(Sac.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
.
at the Contractors License Lew(Chapler g oommencing 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($5001.):
C]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.
slons 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.ll,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 Contractor's License Law dope 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(q licensed pursuant to the Contractors License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sac. ,B 8 P.C.for this reason
IN
Owner Date APPL C IO ATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: Q
C]I have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, ryR p9� Buildinsy
as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which this C` x f
1
permit is Issued. - /j•/(✓H Seismic
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of (,G C ^/ ,
the Labor Code,for the performance of the work for which this permit is issued.My Workers `�r^,
W Total
Compensation Insurance carrier and Policy number are /7 app
Carrier 1'I-Qh Il Policy No. PERMITAUTHORIZAT DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N,C,p
(This section need not be completed If the permit Is for one hundred dollars($100)or less.) (fl.
I certify that In the performance of the work for which this permit Is Issued,I shall not employ
any parson in any manner so as to bete lect to the Workers'CDmPensation Laws of Cali. All roofs shall be inspected prior to any roofing mat Oil being
fornia. 1 installed. If a roof is installed without first obtaining an
Dared Applicant .1 inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and Wil
subject to the Workers'Compensation provisions of the Labor Coda,you must forthwith comply PP ply with all non point
with such provisions or this permit Shall deemed revoked, source regulations.
I certify that)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 Of coverings tob lass or after.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spection purposes. // {/^'
(We)agree to save,Indemnify and keep harmless the Clty of Cupertino against liabilities,
judgments,Costs and expenses which may In any way accrue against said City In consequence
• of the granting of this permit. SIGWURE OF APPILMANT 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 -