R-5444 PERMIT
APPLICATION FOR CITY of CUPERTINO NUMBERR_ 5444
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
/OZ- r rIGwood 17 RESIDENTIALCOMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAMEroof assembly is required.
NO Initial I.C.B.O.#
ADDRESS I EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS 1
CONTRACTO
NAME '
,NOAlt TO BE REMOVED TO BE RETAINED
w ���
ADDRESS T - TYPE OF ROOF COVERING
CITY&ZIP
rVa� A�Willi EXISTING
PHONE„ BUILT-UP ROOF ❑
LICENSEL ASPHALTSHINGLES ❑
NUMBER
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 full force and
eff
Lien yY 7Z
WOOD SHINGLES ❑
License Class LIC.Number
Date I Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARAT N PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sac.7031.5,Business and Professions Cards: 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 Contractor's License Lew(Chapter 9(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 ❑
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than live hundred dollars($500).): WOOD SHAKES
❑I,as owner of the property,or my employees with wages as their sole compensation,will do ❑
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profes-
sions Cade:The Contractors License Law does not apply to an Owner of property who builds or WOOD SHINGLES ❑
Improves thereon,and who does such work himself or through his own employees,provided that
such improvements are not intended or offered for sale.Il,however,the building or Improvement
Is sold within one year of completion,the owner-bullder will have the burden of proving that he did OTHER (SPECIFY) ❑
not build or Improve for purpose of sob.).
I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractors)licensed pursuant to the Contractors License Lew. PROVIDE MFGR.IN$TALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Deb APPLICATION DATE UATION PER IT E
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: r
1 have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, r
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this AUG BUI5
permit is issued. REC71 S; C
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of CITY Uf !!
the Labor Code,for the performance of the work for which this permit Is issued.My Workers / V U�t fnv Total
Compensation Insurance Car ri and Icy number are: q !'{f
Carrier ^� Policy No.
Oo• PERMIT AUT TION DATE
CERTIFICATE OF EXEMPTION FROM WORKER
COMPENSATION INSURANCE N.C.
(This section need not be completed It the permit is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which INS permit Is Issued,1 all not employ
any person In any manner so as to become subject to the Workers'Compan Laws of Cali- All roofs shall be i5spictecil5riortoany roofing material being
forma. installed. If a roof is installed without first obtaining an
cate� �Applicant / inspection,I agree to remove all new materials for inspection,
N ICE TO APPLI AN IL after makln this ertificate of Exigilill you should become Applicant understands and will
subject to the Workers'Compensation provisions of the Labor Cope,you must forthwith comply PP comply P y with all non point
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 county ordinances and Stale laws relating to building construction,and All roof coverings to be lass"C"or better.
hereby authorize representatives of this city to enter upon the above mentioned property for In-
spection purposes. 4� ��
(We)agree to save,indemnify and keep harmless the City ai Cupertino against liabilities,
judgments,costs and expenses which may in any way accrue against said City in consequence �SI�PNATIJRE APPLICANT DATE 7-
of the granting of This permit.
• 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