R-5690•
___ OFFICE COPY
PERMIT
5690
APPLICATION FOR CITY OF CUPERTINO NUMBERR_
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (406) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
!l�_
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
YES ❑ If yes — I understand that a Class A
NAME
I assembly is required.
NO Initial I.C.B.O. If
Pry 2I`
� if- r—
ROOF COVERING
ADDRESS -,262,26 /Z f
IfEXISTING
PHONE
NUMBER OF EXISTING COVERINGS O6V�_
/
y
CONTRACTORR''SJ
NAME C..— F"
TO BE REMOVEDTO BE RETAINED
ADDRESS�S
TYPE OF ROOF COVERING
CITY & ZIP
EXISTING
f
�'o - 2 9f' - /86
PHONE
BUILT-UP ROOF ❑
NUMBER Z
ASPHALTSHINGLES �-
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B (Commencing with Section
WOOD SHAKES CrJ✓
7000) of Division 3 of the Business and Professions Cotle, and my Ilcense Is In full force and
effect,
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�q �/
WOOD SHINGLES ❑
License Class Lic. Number
?'('f?
OTHER (SPECIFY) ❑p
Date Contractor
OWNER -BUILDER DECLARATION
I hereby that I from Contractors License Law for following
PROPOSED O
affirm am exempt the the reason.
(Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to
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j
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 Law (Chapter O (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 five hundred dollars ($500).):
I,
W ❑
WOOD HAKES
❑ 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.
dons Code: The Contractor's License Law does not apply to an owner of property who builds or
WOOD SHINGLES EJ
Improves thereon, and who does such work himself or through his own employees, provided that
such improvements are not Intended or offered for sale. It, 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) El
build or improve for purpose of sate.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct
the project (Sac. 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 contractor(s) licensed pursuant to the Contractor's License Law.
PROVIDE MFGR. INSTALLATION SPECS.
❑ 1 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 following declaration:
❑ I have and will maintain a Certificate of Consent to self -insure for Worker's Compensation,
BuI
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
is Issued.
p I D
P A
permit
❑ 1 have and will maintain Workers Compensation Insurance, as required by Section 3700 of
Suis is
the Labor Code, for the performance of the work for which this permit Is Issued. My Worker's
Compensation Insurance Carrier and Policy number are:
Q9
�IS
Total
C9 Q
,>Z -EA.,, 4 �1 FoncyNo.O
wwPrrERMITAUTHORIZATION
Carrier `N
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' CI
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 this permit is Issued, I shall not employ
All roofs shall be inspectT3d prior torooting rinnitliffial bein
any person In any manner so as to become subject to the Workers' Compensation Laws of Cell-
fornix.
installed. If a roof is installed w thout first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It; alter making this Certificate of Exemption, you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
Applicant understands and will comply with all non point
PP P Y 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 county ordinances and state laws relating to building construction, and
All roof coverings to be class' rbetter.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
sp(Wenagreeaea.—�9
(We) agree to save, and keep harmless the Clry of Cupertino against stabilities,
_l�Iih/o�G•.0/. 47
expenses
ofjudgments,the gran costs and expenses which may In any way accrue against said Clry In consequence
of the granting of this permit.
SIGNATURE OF APPLICANT 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
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