R 5788 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 5788
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
• 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL.—COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME � '� "� ' roof assembly is required.
NO ❑ Initial I.C.B.O.q
ADDRESS X71 Ca__,_� - EXISTING ROOF COVERING
PHONE 4/GQ NUMBER OF EXISTING COVERINGS If
CONTRA li'S
/ TO BE REMOVED TO BE RETAINED
NAME
ADDRESS j 2'^' / 17 TYPE OF ROOF COVERING
CITY&ZIP 4 9
///, EXISTING
PHONEW SV>4-9 3 --6 3 7 3 BUILT-UP ROOF ❑
LICENSE ❑
NUMBER Z 7 O D - ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
hereby affirmthat I em licensed under provisions of Chapter a(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and
ellen} WOOD SHINGLES ❑
License Clas _.SLCLJ—_ Llc.Number ` s+
'Date 7�i719Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECIARAi 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,after,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 Coulmctor's License Law(Chapter 9(commencing with Section 70001 of Division 3 0l 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($500).):
Li 1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not intended or offered for sale(Sec.7044,Business and Profes-
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES
improves thereon,and who does such work himself or through his own employees,provided that ❑
such improvements are not intended the
offered for edea. ill however,the en of pr of Improvement ��•p/t�
not bull sold thinor
provne efrourpose of Sale.).
Owner-builderwlll have the burden of proving that he did OTHER(SPECIFY) rC{�{sM.V
not build or Improve for purpose of sale.).
-❑1,as owner of the property,am exclusively contracting with licensed contractors to construct !� nIC S/7—/
/Z /
the project(Sec.7044:Business and Professions Code:The Contractor's License Law does not PFIRVIfD�F I.C.B.O.REPORT NO.G
apply to an owner of property who builds or improves thereon,and who contracts for such projects P ;
with a contractors)exempt
uicen Se pursuant to the Contractor's License Law. I I PROVIDE MFGR.INSTALLATION SPECS.
- ❑I am exempt under Sec. ,B&P.C.for this reason IV
Owner Dere APPLICA I E VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION G'I( .
I hereby affirm under penalty of perjury one of the following declaration: - t, O O
❑I have and will maintain a Certificate of Consent to self-Insure for Workers Compensation. �t�rrtV i Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this IxIY•/
Per t is issued. . 7 1 7 q S-C
�1�$^/J have and will maintain Workers Compensation Insurance,as required by Section 3700 of SelsfnlC `
the Labor Code,for the performance of the work for which this permit is Issued.My Worker's i
Compensation Insuf¢ncaill er Policy number are: / Total o J
Carrier 42 u rA- LSC Policy No. S 7! -97-//zs PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATIONINSURANCE N.C.O
(This section need not be Completed if the permit is for one hundred dollars($100)pr less.) _ _
I certify that In the performance of me work for which this permit Is issued,I shall not employ
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_2/ 99' Applicant inspection,I agree to remove all new materials for inspection.
NOT CE TO subject I.the Workers'APPLICANT:
mpansation provisions of the L or Code,s Cenifica of yoExemption,you ehoultl become Applicant understands and will Comply with all non point
with such provisions or this permit shall be deemed revoked. I'OU must forthwith comply source regulations. p y
I certify that l 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 All roof eirinasto be class"C"or better.
herebby
hereauthorize representatives of this city to enter upon the above-mentioned property for In.
y
purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against Ilabllltiea,
Judgments,costa and expenses which may In any way accrue against said City In consequence
' of the granting of this permit. SIGNATURE FAPPLICANT 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 _