R 5880 PERMIT
APPLICATION FOR CITY of cuPERrINo R- 5880
NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF.PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 700 DAYS OF PERMIT ISSUANCE OR
• 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS //�
Ale-
W (/�L✓D RESIDENTIAL COMMERCIAL OTHER
HAZARDOUS FIRE AREA
NAME .�/tih//e ms/G GF��Z�� /ad �� YES ❑ If yea I understand that a Class A �.
root assembly is required.
NO ❑ InNal I.CC,B4O.#
ADDRESS EXISTING ROOF COVERING
.. PHONE
NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S
// �(�r7 r�� D Dg TO BE REMOVED_ TO BE RETAINED
NAME L� FO
ADDRESSS.0 t 1 TYPE OF ROOF COVERING
CITY&ZIP /� �N^ S7•
EXISTING
PHONE � L'76 y7 BUILT-UP ROOF ❑
LICENSE
NUMBER Jr Z ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby alllrm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Dods,and my license Is In full force and
effect.
/� y WOOD SHINGLES yZ
License Class `" Llc.Number Z Yr 7 Z' /�
Data 1�= Contractor a G�7 ek, AI OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED pp
I hereby affirm that I am exempt from the Contractor's License Lew for the following reason P A I D
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,alter,Improve,demolish,or repair any structure,prior to Its issuance,also requires the BUILT-UP ROOF �
p� L
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions MAR lL ANSrU
• of the Contractor's LI00080 Law(Chapter B(commencing with Section 70001 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 dollars(5500).): WOOD SHAKES CI I Y lir V'Pm Ln 1 I14U
❑I,as owner of the property,or my employees with wages as their sole compensation,will do LJ
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes.
slons Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES per,
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(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(a)licensed pursuant to the Contractor's License Lew, PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B S P.C.for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
'
I hereby affirm under density of perjury one of the following declaration: ,n I
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Building
as provided for by Section 37W of the Labor Code,for the performance of the work for which this — S/ '
permit is Issued. 7 XV
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of J Seismic
the Labor Code,for the performance of the work for which this permit IS Issued.My Worker's
Compensation Insurance carrier and Policy number are: Total
Carrier � y Policy No.��� ��
PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.
(This section need not be completed If the permit Is for one hundred dollars($100)or lass I ��G
.. 1 certify that In the performance of the work for which this permit Is Issued.I shall not employ V
any person in any manner so as to become subject to the Workers'Companaation Laws of Call. All roofs shall be inspected prior to any roofing material being
feria. r installed. If a roof is installed without first obtaining an
Data 6 — 9? Applicant n�+� e2ol, /4 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 with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP p y p
with such provisions or this permit shall be deemed revoked. Source regulations.
I certify that l have read this application and state that the above Information is correct.l agree
to hereby authorize representatives
rep and se county ordinances and ter a on thel ting above-mentingioned
d prop construction,and All r00 n s IO aSS�C�or better.
hereby authorize repreeentativea of this city to enter upon the abovemantlonetl property for in.
spa purposes. '7
(We)
agree to save,expenses
and keep harmless the City of Cupertino against Ilebllen e, j
judgments,costs and expenses which may In any way accrue against Bald City In consequence IGNATU OF APPLICANT DATE
. of the granting of 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY