R 5972 i
APPLICATION FOR CITY OF CUPERT wo PERMIT
NUMBER R- 5972
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT _ (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
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ Ii yes-I understand that a Class A
NAME �to�cs ® �� 'b roof assembly is required.
NO ❑ Initial I.C.B.O.a
ADDRESS / EXISTING ROOF COVERING
PHONE '� 67677 NUMBER OF EXISTING COVERINGS /
CONTRA R'S
TO BE REMOVED / TO BE RETAINED
NAME
ADDRESS ��/ 7, /� /m/f /y��3 TYPE OF ROOF COVERING
CITY&ZIP (( ( ( C. `7"7 CJ
EXISTING
PHONE BUILT-UP ROOF '❑
LICENSE �,"
NUMBER d' ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter S(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In lull force entl
edea. 3 WOOD SHINGLES ❑
License Class Llc.Number��
Date Contractor OTHER (SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt train 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 a BUILT-UP ROOF 0
applicant for such permit to file a signed statement that he Is licensed pursuant to the provislo
or the ssContractors o Licensesions Law or that a(commencing withSectionand the b of Division 3 0l
• Business entl Professions f Code)or thet he Is exempt therefrom end the basis for the all ASPHALT SHINGLES V
exemption.Any violation of Section 7031.5 by any dollars($5 ant for a permit subjects the applicant t
e civil penalty of not more than floe hundred employees
yeewith
wage:
❑Lae owner thesthcture root I tended oyeeered wegeeas(Sec. rsole44,compensation will tl c WOOD SHAKES
the work,and the structure le not Intended or offered for sale(Sec.7044,Bu6lnesa and Prole.- Jt`�
alone Cade:The Contractor's License Lew does not apply to an owner of property who builds or OD SHINGLES V
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 J�
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY)
not build or Improve for purpose of sale.).
I]I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.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 contractors)licensee pursuant tome Contractor's license Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑I amm exempt under Sac. ,B 8 P.C.for this reason
Owner Aare
WORKER'S 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&ell-Insure for Worker's Compensation, Building
permit Is Issued, p QQ�
01 have and will malntaIn WoVnday
mpensetlon Insurance,as required by Section 3700 of 8- 10_C1 4•) S81SfT11C
the Labor ode,for the performhe work for which this permit Is Issued.My Workers 11 1b
Compen on lnaur Incq carrier umber rg: ,�•— ��� Total
carr' H 01flicy No LLl'1,ji:ick_ PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C. T ^ y IQ _9,a
(This section need not be completed If the permit Is for one hundred dollars($100)or I..e.)
1 certify that In the performance of the work for which this permit IS Issued.I shell not employ
any person in any manner&o as to become subject to the Workers'CempsneatiDn Laws of call. All roofs shall be inspected prior to any roofing material being
forma, installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and will comply subject to.he Workers'Compensation provisions of the Labor Code,you must forthwith comply pP ply with all non point
with such provisions or this permit shall be deemed revoked. source regulations.
I certify mat I have reed this application and state that the above Information Is correctI agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof Cf to ba 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,Indemnify and keep harmless the City of Cupertino against liabilities,
judgments,coats and expenses which may in any way accrue against said City Inconsequence
Anna granting of this cermet SIGNATURE OF 1-1 100 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