R 5969 ERT
APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 5969
REROOF PERM) INS408)7 7-322 ION PERMIT WORKEXPIRATIONIS
1408)7773228 PERMIT EXPIRES IF WORK IS NOT STARTER
(!f WITHIN 180 DAYS OF PERMIT ISSUANCE OR
. 180 DAYS FROM)AST CALLED INSPECTION.
BUILDINGADDRESS
(J� RESIDENTIAL � COMMERCIAL _ OTHER
OWN5R' HAZARDOUS FIRE AREA
Ala VES ❑ If yes—f understand that a Class
NAME root assembly is required.
NO ❑ Initial I.C.B.O.It
ADDRESSIA .sEXISTING ROOF COVERING
PHONE — NUMBER OF EXISTING COVERINGS
CONTRACTOR'
TO BE REMOVED–I—TO BE RETAINED
NAME
ADDRESSf �l TYPE OF ROOF COVERING
CITY&ZIP AVAI ,1 �j EXISTING
PHONE '7� kd4EF' /8 5-3 BUILT-UP ROOF ❑
NUMBER ASPHALTSHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter s(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Coda,and my license Is In lull force and
Licen �/%} 5// WOOD SHINGLES ❑
License Class c,�g Llc.Number� (�7"[�L_ ..
Date Contractor
OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION 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,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 g(commencing with Section 7000)of Division 3 of the
• Business and Professions Code)or that he is exempt therefrom and the basis for the elleg d ASPHALT SHINGLES Qp�
exemption.Any violation of Section 7031.5 hundrbyanyappllcentfor°parmlt subjects the appllcaY�
e civil penalty of not more than floe by employees
yeesra(h wage: I/
❑Lea and
the structure
I not I tended oyeffered wages(S c.704heir l,compensation,sand
Pr WOOD SHAKES fIVR-p`S`y1�M�\pf
the work,antl the structure Is not Intended or offered for sale n owner
of property
and Prate
alone Code:The Contractors es ensesuch Law work hi a not applyor through
gh his own of properly who builds or WOOD SHINGLES
Improves thereon,and who dose such work himself or through hie own employees,provided that ❑ c,
such Improvements are not Intended or offered for sale.If,however,the building or Improvement
Is ato within one year of completion,the owner,builder will have the burden of proving that he did ER(SPECIFY) r
not build or Improve for purpose of sale.). `� V
❑1,as owner of the property,am exclusively conlmcting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor'.License Law does not ROVIDE I.C.B.O.REP RT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects Oyv
with aaanlexempt licensed pursuant to the Contractors License Lew.
❑ PROVIDE MFGR.INSTALLATION SPECS..L, �
I am exempt untler Sec. 0 P., 8 C.for rale reason
Owner Date
WORKERS COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
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, Building
1 l 1
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this g
permit laissued.
and
❑I have and will malnleln Workerompenaetion Insurance,as required by Section 3700 of Seismic
a' 1 —�L7 Yr
.the Labor Code,for the pedormanc i the work forwhich this permit Is Issued.My Workers
Compen tion Insurance carrier an If numb ar : _ Total
Carr! 16aear"° PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N,C.❑
(This section need not be completed if the permit is for one hundred dollars(81 00)or less.) R I �'�
I certify that In the pedormanca of the work for which this permit is Issued,I shall not am toy
any person In any manner so as to become subject to the Workers'Compensation Laws of Celt- All roofs shall be inspected prior to any roofing material being
fornia. installed. if a roof is installed without first obtaining an
Date Applicant inspection,l agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,atter 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
with such provisions or this permit shalQbe deemed revoked. source regulations.
I certify that I have read this application and stela 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 covAll roof cov�gs to be class"C"or better.
be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned properly for In-
spection purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
judgments,costa and expenses which may In any way accrue against said City In consequence
of me granting of this Parma. 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
OFFICE COPY