R 5808 PERMIT R_ 5808
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
WI180 DAYS FROM LAST CALLED INSPECTION.
BU
I�LDING ADDRESS
UIa-10 & S ICGI f N I� O W r RESIDENTIAL COMMERCIAL OTHER
OWNER'S - HAZARDOUS FIRE AREA
M I_1�A W AVES ❑ If yes–I understand that a class A
NAME �I roof assembly is required.
NO ❑ Initial I.C.B.O.g
ADDRESS J ��j�eft -7 q EXISTING ROOF COVERING
PHONE O — v 15 ( ` • NUMBER OF EXISTING COVERINGS
CONTRAQjQr r 1
Q
NAME a Na I S S A h « •_0 a4l; h 9 TO BE REMOVED TO BE RETAINED
ADDRESS 'a'a Gr L i In C D I Yi 1A-V& STcISI 2,r TYPE OF ROOF COVERING
CIN&ZIP
PHONE EXISTING
�fC�g� ���—obg7 BUILT-UP ROOF ❑
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Cotle,and my license Is In lull force and
effect, . G 3C7 SS-7—7 WOOD SHINGLES ❑
License Class Lie.Number
[)ate I- Contractor JQaKd sSislnce H OTHER(SPECIFY) ❑
OWNER BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors License Law for the following reason.
(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
applicant for such permit to file a Signed statement that he Is licensed pursuant to the provisions
of the 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 4ay QFVUftri mo
a civil penalty of not more than five hundred dollars($500).): WOOD SHAKES
El 1,as owner of the property,or my employees with wages as their note compensation,will do ❑ I
the work,and the structure Is not Intended or offered for sate(Sec.7044,Business and Profes.
sions Code:The Contractors 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 sate.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 Sate.).
❑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 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
with a contractor(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
1 hereby affirm under penalty of perjury one of the following declaration: ^v
❑ haveand will malnt37a of the
Labor
Consent toeperformafor of the
oCompensation, D(� Building G
as provided have
lardy Section maintain
a o1 the Lobar Code,for the performance for
work for Compenhich sation,
U g
isermlti sued.
ave and will maintain Workers Compensation Insurance,as required by Section 3700 of / 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: '/� ^ �s Total
Carrier `S a h� Policy No. �µrJ _3 -99
PERM UTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.E]
(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 Issuedshall not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Cali. All roofs shallA inspected prior to any roofing material being
fornia. installed. It a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: II,after making this Certificate of Exemption,you should become Applicant understands and will cam
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP ply with all non point
with such provisions or this permit shall be deemed revoked. source regulations.
I certify 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 coverings to be class"C"or better.
hereby authorize representatives of this city t0 enter upon the above-mentioned property for In.
spection purposes. I/� (�1'
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, W � al 4.Q r1 Q
judgments,coats and expanses which may In any way accrue against said City 4n consequence
ju me granting of alis expenses
permit. SIGNATUTIE 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