R 5967 PERMIT R_ 5967
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOFPERMI 1 (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 L
6 T RESIDENTIAL COMMERCIAL OTHER—
OWNER'
THEROw ER' _ HAZARDOUS FIRE AREA
VES ❑ Ifyea—Imbly isand equire aClasSA
NO roof assembly is required.
❑ India) I.C.B.O.q
EXISTING ROOF COVERING
PHONE % V g NUMBER OF EXISTING COVERINGS
CONTRAC R'S - _ '
NAME To BE REMOVED TO BE RETAINED
ADDRESS �f} / TYPE OF ROOF COVERING �L—
CITY&ZIP •S V
EXISTING
PHONE BUILT-UP ROOF ❑
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES FOrYI
7000)of Division 3 of the Business and Professions Code,and my license le In full force and
affect' WOOD SHINGLES
License Class - Lic.Number �`7 [— SACC ❑
Date Convector OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors 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 file a signer)statement that he Is licensed pursuant to the provisions 8. V
of the Contractor's License Law(Chapter B(commencing with Section 7000)of Division 3 of the 1�\
• Business and Professions Code)or that he Is exempt therefrom and the basis for the elle ASPHALT SHINGLESO `v
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant
a civil penalty of not more than five hundred dollars($500).):
❑1,as owner of the property,or my amployaos with wages as their sale compensation,wllld WOOD SHAKES .\ J
the work,and the structure is not Intended or offered for sale jSoc.7044,Business and Praise. V V
alone Coda:The Contractor's License Law does not apply to an owner of property who builds or W0 SHINGLES 4J�
Improves thereon,and who does such work himself or through his own employees,provided that
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 ER(SPECIFY) �❑
not build or Improve for purpose of agile.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Cotle:The Contractor's License Law tloes 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 contrectogs)licensed pursuant to the Contractors License Law. PROVIDE MFG R.INSTALLATION SPECS./_4
[:11 em exempt under Sec. ,B&P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
CI I have and will maintain a Certificate of Consent to self-Insure for 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. . 10 —9s
❑1 have antl will maintaln Worker's C Creation Insurance,as required by Section 3700 of 9iaaY Seismic
the Labor Cotle,for the Part
a rk f0r Ich this permit is Issued.My Workers ('• 'r 1
Compen on Insurancq,parrier and y n bar ar : Total
Der cyNo. PERMIT AUTHORIZATION DATE
CERTIFICATE EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N00)o l O —_I O
(Tela section need not be antecompleted
the
If the permit Is for one permit
I sI dollars($100)or lose.)
amity that in the performance of the work for which W permit le Issued,I anal)not employ
any person m any manner so as to become subject m the warkerd campensauon Laws m ceu- All roofs shall be inspected prior to any roofing material being
torula. installed. If a roof is installed without first'obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
subje�toEheOWorrkeres'Compef,after nsation making
ls ofetheflcate of Laborr Code,Exemption,
mustufo fortd become
hwith comply Applicant understands and will comply with all non point
with such provisions or this permit shairbe deemed revoked. Source regulation.
I certify that I have read this application and state that the above Information Ie Correct.I agree
to comply with all city and county ordinances and State laws rotating to building construction,and All roof coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes. p—
(We)agree to save,Indemnity and keep harmless the City at Cupertino against liabilities,
judgments,costa and expenses which may In any way accrue agalnet sold City In consequence SI ATURE OF7IFPLIC NT DATE
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