R 5751 APPLICATION FOR CITY of cuPERTINo
NUMBER R- 5751
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 LAST CALLED INSPECTION.
BUILDING ADDRESS
o
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
NAME —}�/Vl/ �/.,L�✓Li SES ❑ root assem assembly
is required.Mat. Class A
bly is required.
�+ NO ❑ Initial- LC.B.O.#
ADDRESS c '�-1y '� �^ EXISTING ROOF COVERING
PHONE �J / O 3 S NUMBER OF EXISTING COVERINGS
CONTRACT �F�S TO BE RETAINED
NAME / TO BE REMOVED
ADDRESS 3O �] - TYPE OF ROOF COVERING
CITY 8 ZIP t.liG�e
�.
I/G EXISTING
PHONL�S2�SQQN T ` .3 0 3 3 BUILT-UP ROOF ❑
CENSE
NUMBER D :2 Q O ASPHALT SHINGLES ❑ i
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under proylslons of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of.the Business and Professions Code,and my license Is In lull force and
meet. y�' 2 WOOD SHINGLES ❑
License Class � Lic.Number • � I
Date �� 44 comracior OTHER(SPECIFY) ❑
OWNER-BUILDER DECIARATIOI PROPOSED
I hereby affirm that I am exempt from Me 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 ap n
of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the p pa I
• 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($500).): � / ^ n
[11,as owner of the property,or my employees with wages as their sale compensation,will do WOODS'� 30 ANSI IY�L�
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes.
sions Coda:The Contractors License Law does not apply to an owner of property who builds or WOODtHING�i ES ❑
improves thereon,and who does such work himself or through his awn employees,provided that •,. •_.•••�•-�
such Improvements are not Intended or offered for sale.It,however,the building or Improvement -
Issoldwlthlnoneyearolcompletion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not b 1,as owner
improve ler purpose of sere.).
❑I,ecowner 01 the property, and
sCodlingwithntracteticontractorsto construct C
the project owner f pr Business Dorf Pr or improv Code:The Contractor's License for
Law does not PROVIDE LC.B.O.REPORT NO. S Q
apply to ntowner of property who builds orlmpmvesthereon,and who contracts for ouch protects
with a c m exempt licensed pursuant to the contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I em exempt antler Sec. ,B 8 P.C.for this reason
OwnerDate
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: C�
❑1 have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, ,� Building�J C7Q
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit Is Issued, Q /// /
p ❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of ��/ `L Y��� G seismic O
the Labor Code,for the performance of the work for which this permit Is Issued,My Workers Sp�p 2-•D
Compense' n In^s rans�cle carrier and Policy number are: Total
Carrier '`' �li^^d� Policy No.15V —! 7 I�2s pERMITAUTHORIZATION DATE ,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.]
(This section need not be completed If the permit le for one hundred dollars($100)or lees.) p 0
I certify that in the performance of the work for which this permit Is Issued,I shall not employ 1 ( �G
any person in an manner so as to become subiact to orkars•Compensallon Lawa of call- All roofs shall be inspected prior to any roofing material being
fernla. L c installed. If a roof is installed without first obtaining an
' Dale go G Applicant '�✓�/ inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,shat making this Certificate of Exemption,you should become Applicant 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
with such provisions or this permit shalQbe deemed revoked. SOUfCa regulations.
I certify that f have read this application and state that the above Information Is correct.)agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof covert Obe ClasS;Borbetter.
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 Iiabllllles,
judgments,costs and expenses which may In any way accrue against said City In consequence J
of the granting of this permit. SIGNATURE O'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