R 5795 PERMIT R_ 5 7 9 5
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 160 DAYS OF PERMIT ISSUANCE OR
160 DAYS FROM LAST CALLED INSPECTION.
BUILDING A�D�DRESS �/r/� - -
Z2�7o (/ Q G✓2S�" RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
VES El If yes I un a Class A�) �x� rot6snblyisregired.
NAME
Ino I.C.B.O.k
ADDRESS EXISTING ROOF COVERING
` PHONE �� ! ' NUMBER OF EXISTING COVERINGS
r CONTRACTO '
70 BE REMOVED TO BE RETAINED
NAME
ADDRESS fYPE OF ROOF COVERING
CITY&ZIP EXISTING
PHONE BUILT-UP ROOF ❑
E
LICENS - El1141 1
NUENASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 6(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and
WOOD SHINGLES ❑
License Class Lic.Number
Data Contractor
OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
1 hereby affirm that I am exempt from the Contractor's License Law for the following reason.
IS
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
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 ❑
e�xem�p�tion.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
civil nally of not more than floe hundred rap,tloilere($500).):
• as owner ofineproperly,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑ `
we
the structure Is not Intended ores not for eels n ow er of rosiness and Protea-
slons Code:The Contractor's License Low does not apply to an owner of property who provided
orImprWOOD SHINGLES
such improvements
o thereon,and ar who doessuchwork edforf orthrough wev own employees,or provided lent ❑
such Improvements era not Intended or offered for sale.l(however,the Wlltling or Improvement I
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) El
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'.License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improve&thereon,and who contracts for such projects g
with a contractor(s)licensed pursuant to the Contractor's License Law. PROVII�Ih�N?GR. INSTALLATION SPECS.
❑ em exempt under Sec. ,B B P.C. r t r s
wne WORKER'S COMPENSATION DECLARATION AP VALUATION PERMIT FEE
ereby affirm under penalty of perjury one of the following decleratlon: 7�,
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, CI1 I (JI: Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this t.Cry ITN g
`
permit Is have
ntl. Seismic
❑ have ane will maintain Workers f the work
for Insurance,as required Is
by Section 3700's
_the Leber Code,for the performance of the work for which this permit le Issued,My Worker's
Compensation Insurance terrier entl Policy number are: Total
Carrier Policy No. PERMIT AUTHORIZATION DAT
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.I] Te
(This section need not be completed If the permit Is for one hundred dollars(III lase.)
I certify that In the performance of the work for which this permit Is Issued,I shall not employ fill
any person In any manner so as to become subject to the Workers'compensation Laws of Cali- All roofs shall be inspected prior 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,akar making this Certificate of Exemption,you should become
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply Applicant•hcant understands and will comply with all non point
with such provisions or this permit shalfbe 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 slate 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-
epection(We) purposes. 15'
(�
(We)agree to neve,Indemnify and keep harmless the City of Cupertino against Ilebllence Q
judgments,costs and expanses which may In any way accrue against said City in consequence NATURE OF APPLICANT
. of the granting of this permit. - 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
0FFICE COPY.