R-5642 PEUp
APPLICATION FOR CITY OF CUPERTINO
NUMBERR- 5642 .
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
O r ?E I> I re L M . RESIDENTIAL COMMERCIAL OTHER
OWNER'S �j ' ' HAZARDOUS FIRE AREA
i' YES ❑ If yes—I understand that a Class A
NAME /✓ V roof assembly is required.
/j /� ,/& NO E] Initial I.C.B.O.#
ADDRESS A Ij EXISTING ROOF COVERING
PHONE S-7 ✓Q/ 1-7 IS - NUMBER OF EXISTING COVERINGS /
CONTRA
NAME Tp���
//_7) 1/y` TO BE REMOVED TO BE RETAINED
ADDREss 7� Bd y c Crn' GO ��Or� TYPE OF ROOF COVERING
CITY sZIP a T�-i EXISTING
PHONE 6S'�Sl BUILT-UP ROOF ❑
LICENSE
NUMBER �I� � / ASPHALT SHINGLES ❑
O� 7 10
LICENSED CONTRACTORS DECLARATION ' `
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES JI"j'L�
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect.
��j WOOD SHINGLES E]License Class Lic.Number /
Data g Con bacfar OTHER(SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason. p /
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to V o
construct,alter,Improve,demolish,or repair any structure, to Its issuance,also requires the BUILT-UP ROOF ❑ 9
applicant for such permit to file a signed statement that he is licensed pursuant to the previsions
of 110 Contractor's License Law(Chapter 9(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 Xa civil penalty of not more than five hundred dollars($500).):
❑ WOOD SHAKES I,as owner of the property,or my employees with wages as their sole compensation,will do ❑
the work,and the structure Is not intended or offered for sale(Sec.7044,Business and Profes.
sions Code:The Contractor's License Law 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) El
build or improve for purpose of sale.),
❑1,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 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
with a contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: ...5
p 1 have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, D Building 1//LJ/
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this -�
park,Is mi ued.
rhave and will maintain Worker's Compensation Insurance,as required by Section 3700 of Seismic
thbar Code,for the performance of the work for which this permit Is Issued.My Worker's %i�, D
Compensati n Insurance Carder antl Policy num er are: Total
Carrier � �: PollNoC% 7(20 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need not be completed If the permit Is for one hundred dollars($100)or less.) '� 2 ` O
I certify that In the performance of the work for which this permit is Issued,I shall not employ lJ 1Q
any person in any manner so as to become subject to the Workers'Compensation Laws of Cali- All roofs shall be inspected prior to an tlhg material being
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,l agree to remove alsffrnitffi fE 7Unspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become A
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 shall be deemed revoked. source regulations. CIIY Vr NVrrn I mu
I certify that I have read this application and slate 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 Brings to S "C"Ofbeffer.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection
n-
se,wit) purposes. WL�1 l�.L•�CJ w' ��
(We)ts,co to save,expenses
and keep harmless the City of Cupertino City...
i against liabilities,
judgments,costa and expenses which may in any way accrue against sold City In coreequanee• SIGNATURE OF APPLICANT DATE of the granting d 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY