R 5973 t�
PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 5 9 3.
REROOF PER INSPECTION DIVISION PERMIT EXPIRATION
(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�y,////� / / /
RESIDENTIAL _�/ COMMERCIAL OTHER
ow ER' HAZARDOUS FIRE AREA
YES ❑ .If yes-I understand that a Class A
NAME roof assembly is required.
`... NO '❑ Initial I.C.B.O.I
ADDRESS cS EXISTING ROOF COVERING
PHON - �i D 5O NUMBER OF EXISTING COVERINGS
CONTRAPTORS /
t TO BE REMOVED--[-- TO BE RETAINED
NAME
ADDRESS / TYPE OF ROOF COVERING
CITY&ZIP EXISTING
PHON BUILT-UP ROOFLICENSE
❑
NUMBERASPHALT 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 full force and
poet. WOOD SHIN
L^/ ` ��—
License Class JL..�(�1� Lic.Number ��
OTHER(SPE
DelpOWNER-BUILDER
,\G 6
OWNER�BUILDER DECLARATION I l�
hereby affirm that em exempt from the e: Anyt city License Law for the following r/ n.
PROPOSED
(Sec.7031.5,Baines and Professions it any Any city or county which requires a perm)
construct,alter,improve,demolish,orrepeireny structure,prior to Its Issuance,also requires the BUILT-UP R00
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractors Ucanse Lew(Chapter a(commencing with Section 7000)of Division 3 0l the
• Business and Professions Code)or that he is exempt therefrom and the basis for the alleged SPHALT SHING ❑
exemption.Any vlotation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not mora than live hundred dollars($500),): 1'
❑1,as owner of the properly,or my employees with wages as their sole compensation,will do WOOD SHAKES
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes-
sions Code:The Contractor's License Lew does not apply to an owner of property who builds or WOOD SHINGLES
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 OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑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 Q ��
with a contractors)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for this reason
Owner DeAPPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: I q l
❑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 Cotle,for the performance of the work for which this _
permit lave and og-Z(o-98 Seismic
❑I have and will the pelrf Work a C the wokmillfor which this as required Is I su Sectiod.My
3700 of V 1 V
the Labor Code,for the performs of the work for which this permit Is issued.My Warkere
Compo lion Insurance carrier Pat ynumb rare: �(� �/,�//�� • `-- Total
Ca /y/1�.✓/CLZ�4L1/-►•silty No,Tue`-a��C�L PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.] 2 p
(Thio section need not be completed If the permit Is for one hundred dollar$($100)ar lase) 0 n ��� 00-210-98
I certify that In the performance of the work for which this permit Is Issued,I shall not employ
any person In any manner so as to become subject to the Workers'Compensatlen Laws of Call. All roofs Shall be inspected prior to any rooting material being
torula. 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 become Applicant understands and will
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP comply P y with all non Poral
with such provisions or this permit shaffbe deemed revoked, Source regulations.
I certify that l have read this application and state that the above information is correct.)agree
to comply with all city and county ordinances and state laws relating to building construction.and All roof covert n ato be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
ap epurpose.
fW )
(We)agreesave,Indemnify and keep harmless the City Cupertino against liabilities, Z
judgments,coatss and expanses which may In anyway accrue against
nst seltl City In ceneoquence
• of the grating of permit. SIG RE 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