R 5017 96yy9 i
PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 5 017
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
t ^ ,/ RESIDENTIAL COMMERCIAL OTHER
WNE P HAZARDOUS FIRE AREA
NAME ( /rQ n �Q YES ❑ If yes—I understand that a Class A
roof assembly is required.
NO 0 Initial I.C.B.O.g
ADDRESS
EXISTING ROOF 9OVERING
PHONE
NUMBER OF EXISTING COVERINGS
CONTRACTOR'S �/�•
NAME L .S' Q 'J ( j'L.E� TO BE REMOVED TO BE RETAINED
ADDRESS .I�Q D dX h�1 / TYPE OF ROOF COVERING
CITY&ZIP iii' D ,/GLP
Z33 95° 3 EXISTING
PHONE (/ BUILT-UP ROOF ❑ -
NIUMBER % ASPHALTSHINGLES ❑
LICENSED CONTRACTORS DECLARATION /
)of 01 affirm that am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business entl Professions Code,and my license la I f I lone entl
effect. //� �/yWOOD SHINGLES E]License Class 39 Lic.Number
Date Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED /
hereby affirm that I am exempt from the Contractor's License Law for the following reason.
IS
7031.5,Busin°ea and Professions Code: Any city or county which requires a permit to
construct, her,improve,tlemolish,or repair any structure,prior to its Issuance,also requires the BUILT-UP ROOF 1:1
applicant lar such permit to file a signed Statement that he la licensed pursuant to the provisions
of the Contractor's License Lew(Chapter g(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
40 e civil penalty of not more than five hundred dollars($500).):
[ I,as owner ofthe 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 Profen
slons 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 with In one year of completion,the own°r•bullder will have the burden of proving that he did OTHER (SPECIFY) ❑
not build or Improve for purpose of sale.).
0I,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 bullds or Improves thereon,and who contracts for such projects
with a contexem t licensedrSe pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.�t�
am exempt under Sec. ,B 8 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATEI VALUATION PERMIT F
I hereby affirm under penalty of perjury one of the following declaration:
❑Ihave and will maintain a of thei Labor
r Consent toself-insure for of
work
Compensation, rdoasDrovided for by Seglon 3700 of the Labor Cotle,for ins parbrmence of the work br which this ''p r t le issued.I have entl will maintain Worker's Compensation Insurance,es required by Sectlon 3700 of
t or Code,for the pa rmence of the work for which this permit Is issued.My Workers
ampen onln rance rlerand Policy number ars: C O s Total
( Carrier Policy No.e7//Sr/�/�32S RMIT Abif IORIZATION DATE
CERTIFICRE OF EXEMPTION FROM COMPENSATION INSURANCE WORKERS' N.C.[ Ul I Y Ur (A I
(This section need not be completed If the permit Is for one hundred dollars($100)or less)
I certify that In the performance of the work for which this permit Is issued,1 shall 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 a roofingm erial e'
fornia, installed. It a roof is installed wit out first O lainin an
Date Applicant inspection,I agree to remove.all new materials for inspection.
subject to Eh worke�s'Compent Oo promaklvisionls of thelcate LaborCode,yourm must
forthwliithbecome
comply Applicant understands and will comply with all non point
with such provisions or this permit shallibe deemed revoked, source regulations.
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 cover to be class"C"Or better.
herebyauthorize purposes,representatives of this dry to enter upon the above-mentioned property for Ira
ap(We) purposes. 7
(We)agree to save,Indemnity and keep harmless the City ai Cupertino against liabilities,
at the gran costa and expenses which may In any way accrue epalnai said Clry In consequence
of the granting of this permit SIGNATURE 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
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