R 5970 PERMIT R_ 5970
APPLICATION FOR CITY of CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS ' /
II '4RESIDENTIAL ✓ COMMERCIAL OTHER
OWNER' HAZARDOUS FIRE AREA
d-VVES ❑ If yes—I understand that a Class A
NAM01" roof assembly Is required.
NO ❑ - Initial I.C.B.O.N
ADOREss EXISTING ROOF COVERING
PHONE 6 NUMBER OF EXISTING COVERINGS •�
CONTR TOR'S
NAME
S TO BE REMOVED_/_TO BE RETAINED
ADDRESS / TYPE OF ROOF COVERING
CITY&'ZIP
EXISTING
PHONE'kZ1167- ��✓
BUILT-UP ROOF ❑
LICENSE —
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter g(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and
.tied. WOOD SHINGLES ElLicense Class Uc.Number
Date Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED e® 4O
I hereby allirm that I am exempt from the Contractors License Lew for the following reason.
(Sec.7031.5,Business and Profession.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 �❑ `(q' l7
applicant for such permit to file a signed statement that he is licensed pursuant to the provision
•
of the Contractor's License Lew(Chapter B(commencing with Section 7000)of Division 3 of th
Business and Prot...Ion.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 lore permit subjects the applicant `ZL e civil penalty of not more than live hundred dollars($500).):
❑I,as owner of the property,or my employees with wages as their sole compensation,wllld WOOD SHAKES
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes-
aloneCode:The Contractors License Law does not apply to an owner of property who builds or 11WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,provided that V
such Improvements are not Intended or offered for cele.If,however,the building or Improvement
Is said within one year of completion,the owner-builder.111 have the burden of proving that he did -11. (SPECIFY) ❑
not build or Improve for purpose of sale.).
01,as owner of the property,em exclusive contractlng with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Lew 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 �y
with a contt)treatedpursuant to the Contractor's License Lew.
E] exemp
PROVIDE M FGR.INSTALLATION SPECS,J�,R
I em exempt under
Sec. ,e 8 P.C.for dhla reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: U1_1❑1 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 isIssued. c 8��o_Qa Seismic
❑I have and w111 the pert Workers Comp Atha
worllionk
Insurance,as required Is I su Section Worker's's
the Labor Code,for the performance the work for which ihl9 permit le Issued.My Worker's Of Total
Compo ellen insurance cy n �mb�erJe�.
Ca JZ;/ aFp1(cyhlsQ�Y/ dP`&& 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 c llsre($100)or tae..) O $ — to-q
I certify that in the Performance of the work for which this permit Is IesueQ I.hell not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Cell- All roofs shall be inspected prior to any roofing material being
forms. installed. If a roof is installed without first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should becopme Applicant comply
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith Com pp nt understands and will coin I 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 state laws relating to building construction,and All roof COVef sto be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spection purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino ageinat liabilities,
judgments,coeds antl expenses which may In any way accrue against said City In consequence SIGNATURE OFAPPLICANT
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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY