R 5155•
PERMIT R_ 515 5
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
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NAME
ADDRESS
CITY & ZIP4�17W
PHONE -
LICENSE
I hereby affirm that I em licensed under provisions of Chapter B (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license Is In full force and
enact.
License Clea` Uc. Number r
7
Date Contractor
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Lew 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
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Law (Chapter B (commencing with Section 7000) of Divlalon 3 of the
Business and Professions Code) or that he is exempt therefrom and the basis for the alleged
exemption. Any violation of Section 7031.5 by anyapplicant for a permit subjects the applicant to
e civil penalty of not more than five hundred dollars (5500).):
Q I, as owner of the property, or my employees with wages as their sole compensation, will do
the work, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Profes.
sions Code: The Contractor's License Lew dose 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
such Improvements are not Intended or offered for sale. II, however, the building or Improvement
Is sold within one year of completion, the owner -builder will have the burden of proving that he did
not build or Improve for purpose of sale.).
[:11, as owner of the property, em exclusively contracting with licensed contractors to construct
the project (Sec. 7044, Business and Professions Coda: The Contractors License Lew does not
apply to an owner of property who builds or improves thereon, and who contracts for such projects
with a contractors) licensed pursuant to the Contractors License Law.
Q 1 am exempt under Sec. ,B & P. C. for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration;
Q 1 have and will maintain a Certificate of Consent to self -Insure for Workers Compensation,
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
permit Is issued.
Q 1 have and will maintain Worker's Compensation Insurance, as required by Section 3700 of
the Labor Code, for the performance of the work for which this permit Is Issued. My Worker's
Compensation IInnsuurrens carrier and Polity nu bar are:
Carrier ` yT,� jQ � Policy No. ;4KE S
CERTIFICATE E67FN EXEMPTION FROM WORKE S'
COMPENSATION INSURANCE N.C.Q '
(This section need not be completed If the permit to for one hundred dollars ($700) or less.)
I certify that In the performance of the work for which this permit Is Issued, I shell not employ
any person In any manner so as to become subject to the Workers' Cc pensalIon Laws����IIII Call-
Date 4` f/ — Y�poolicem �C/� ,A//n/.
subleet to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
with such provisions or this permit shall♦be deemed revoked.
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 state laws relating to building construction, and
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 Ilabllltlea,
judgments, costs. and expenses which may In any way accrue against said City4n consequence
PRE -INSPECTION: I PLYWOOD:
COMMERCIAL OTHER
VES ❑ It yes – I understand that a Class A
17QV roof assembly is required.
NO Initial I.C.B.O. a
NUMBER OF EXISTING COVERINGS
TO BE REMOVED </ TO BE RETAINED
BUILT-UP ROOF ❑
ASPHALT SHINGLES ❑
WOOD SHAKES
WOOD SHINGLES ❑
OTHER (SPECIFY) ❑ _
BUILT-UP ROOF
ASPHALT SHINGLES
WOOD SHAKES ❑
WOOD SHINGLES ❑
OTHER (SPECIFY) ❑
PROVIDE I.C.B.O. REPORT NO.
PROVIDE MFGR. INSTALLATION SPECS.
JAPPLICATION DATE1 VALUATION I PERMIT FEE I
SEP 2 61916 ric
Total
PERMIT AUTHORIZATION DATE
\' S�
installed. If a roof is installed without first obtaining an
inspection, I agree to remove all new materials for inspection.
Applicant understands and will comply with all non point
source regulations.
All roof coverings to be class "Cr Her.
SIG A4IRE kFrPLICANr DA
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 I
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