R 7592 =NBE
APPLICATION FOR CITY OF CUPERTINO R_ 7592
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3.226 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDIN DDRESS
RESIDENTIA COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME zil X, roof assembly is required.
NO E) Initial I.C.B.O.k
ADDRESS,,?C.%/.S 11%e')j `e`q )0r EXISTING ROOF COVERING
PHONETRACTOR'S �" NUMBER OF EXISTING COVERINGS
CON
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS TYPE OF ROOF COVERING
CITY&ZIPz�/ kjalz
`, EXISTING
PHONE .7n•� ���9�,34/ _ BUILT-UP ROOF ❑LICENSE
NUMBER (j _ ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license is in Iuil force and
effect' / / (� WOOD SHINGLES El
License Class ll Lic.Number fi
191Q�t
Date Contractor :,.? OTHER(SPECIFY) El/
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the 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 lila a signed statement that he is licensed pursuant to the provisions -
of the Contractors License Law(Chapter 9(commencing with Section]000)of Division 3 of the
Business and Professions Code,or that he is exempt therefrom and the basis for the ellogod 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),I: WOOD SHAKES
I,as owner of the property,or my employees with wages as their solo compensation,will do El
the work,and the structure is not intended or offered for sale(Sec.7044,Business and Profes.
sions Code:The Contractor's License Law does not apply to an owner of property who builds 0r WOOD SHINGLES
improves thereon,and who does such work himself or through his own employees,provided that El
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 01 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
apply to on owner of property who builds or improves thereon,and who contracts for such projects
with a contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
E]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 Iollowing declaration:
1 have and will maintain a Certificate of Consent to sell-insure lot Worker's Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is Issued. ` —/G- 2p,C> —O
[']I have and will maintain Workers Compensation Insurance,as required by Section 3700 o1 ✓ / Seismic
the Labor Code,for the performance of the work for which this permit is issued.My Worker's �.y y/�
Compensation Insurance carrier and Policy number are: Total
Carrier.L..12)LA��>/��Ff�> Policy No. <�t��r!�0— PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need not be completed if the permit is lot one hundred dollars($100)or less.) ,
I certify that in the performance of the work for which this permit is issued,I shall not employ
any person to any manner so as to become subject to the workers'Compensation Lewe of car- 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,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 WIII coin with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply comply P
with such provisions or this permit shall be 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 cou my ordinances and state laws relating to building construction,and _ All roof Coverings to be class46brbetter.
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 City of Cupertino against liabilities, y„
judgments,costs and expenses which may in any way accrue against said City In consequence SIGNATURE OF APPLICANT DATE
of the granting of this permit.
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
- 1INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE'COPY