R 5984 I PERMIT R_ 5984
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
\ (408)777-3228 WITHIN 180 DAYS OF PERMIT ISSUANCE OR
ADDRESS1 180 DAYS FROM LAST CALLED INSPECTION.
I\'
BUILDING
Or
UjOr 7 4) s,d'e, Co,
RESIDENTIAL COMMERCIAL OTHER
r owNER•S T/ HAZARDOUS FIRE AREA
` NAME �S V C/(� / YES ❑ If yes—I understand a Class A
roof assembly is required
NO ❑ Initial I.C.B.O.If
ADDRESS- r�� _ e, EXISTING ROOFCOVERING
PHONE NUMBER OF EXISTING COVERINGS pY
CONTRACTO S
f•
NAME TO BE REMOVED TO BE RETAINED
7—
ADDRESS / TYPE OF ROOF COVERING
CITY&ZIP
EXISTING .
PHONE��j� Q `, moi BUILT-UP ROOF ❑
CENSE
NIUM13ER SPHALT SHINGLES
.LICE SED CONTRACTORSsof Chapter 9(N
hereby affirm that I em Business
under provisos of Chapters(commencing with Sectionand D SHAKES
7000)o/Division 3 of the Business entl Professions DOtle,and my license is In lull force entl
enact. (q P WO HIN ES
License Class_ALL_ Llc.Number
Date Contractor
OTHER IFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Lew for the following reason.
(See.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,altar,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 provislone
of the Contractor's License Lew(Chapter B(commencing with Section 7000)of Division 3 of the
.• Business and Professions 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 for a permit subjects the applicant to
a civil penalty of not more than five hundred doll a Is($500)): y-r�
❑l,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES
the work,and the structure Is not Intended Or Offered for sale(Sec.7044,Business and Profes.
• sions Cotle:The Contractors License Lew does not apply to an Owner of property who Wilds or (�
Improve$thereon,and who does such work himself or through his own employees,provided that WOOD SHINGLESpUrD ❑ ��� �
such Improvements are not intended or offered for eels.If.however,the building or Improvement
Is not
oulld 0hn one year of complallon,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) rV
not bulltl or Improve for purpose of sale.). - -
❑1,as owner Of the property,em exclusively contracting with licensed contractors to construct CCI�I��
the project(Sec.7044,Business and Professions Corte:The Contractor's License Lew does not PROVIDE I.C.B.O.REPDRT NO.
apply to an owner of property who build$or improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractors License Law. PROVIDE M FGR.INSTALLATION SPECS.
El am exempt under Sec. ,B&P.C.for this reason
Owner oma
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: I�
❑I have and will maintain a Certificate of Consent to sotf-Inaure for Workers Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit Is Issued. 08- 11 -900 Seismic
❑ have and will maintain Workers Compensation Insurance,as required Is i su Seaton 3700 01
the Labor Code,for the pedmmance I the work for which rola permit le laeuetl.My Worker's Lila
ComDe/neJsq�on,,Insurancecarrier entl Ic/y number are: ��.r �j Total J Lila.
carr�Jy!!l f1F L �1"IicyN�J&igz4 Tz"L PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NCL]
(Thio section need not be completed If the permit is for one hundred dollar 1$1or lees .f
certify that In the performancee o0th1 the work for which this permit Is issued,1 she11 ll nnot employ ,`
any person In any manner so as to became subject to the Workers'Compensation Laws of Call. Alf roofs shall be inspected prior to any roofing material being
fornix. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
subjectono the WorkersE TO 'Compef,after nsation provisionis of thecate of Labor Code.Exemption,
must fothwshoulltlhbecome comply Applicant understands and will comply with all non point
with such provisions or this permit shell be deemed revoked. source regulations.
I cetify 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 cod R to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In- �y+��• p--
spoction(We) purposes.
�6� U `S O
(We)tssco to ands,expenses
and keep harmless the City ai Cupertino against liabilities,
of tgmanta,costa and expenses wNch may In any way accrue against said City In consequence
onR0gmntingatthispermit. SI�7ATUREOFAPPLICANT 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY