R-5330 APPLICATION FOR CITY OF CUPERTINO
rPE s RR- 5330
■�
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
�/
RESIDENTIAL COMMERCIAL—OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME /N f assembly is required
3 NO Initial I.C.B.O.It
ADDREss EXISTING ROOF COVERING
PHONE J u NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S �-y
l/) z /�i���� TO BE REMOVED TO BE RETAINED
} NAME �Gf� �(/ C.�
ADDRESS q q // TYPE O ROOF CNG
CITY a ZIP •— " � EXISTING
PHONE 1Q1 BUILT-UP ROOFLICENSE
J
NUMBER l / ASPHALT SHINGLES E-1
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 t e Business and Professions Code,and my license Is In full force and
effect' itl �� WOOD SHINGLES - El
License C e I Lie.Number
OTHER(SPECIFY) ❑
Date i Contractor
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's 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 Elapplicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractors License Lew(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 p�
a civil penalty of not more than live hundred dollars($500).): WOOD SHAKES r �®
❑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. p/�
slons Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES APR
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 C
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY);J'l •/�[/
not build or Improve for purpose of sale.). Y Vf L(J�Ek�) ^
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct Crl (� QFr
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 contractors)licensed pursuant to the Contractors 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:
❑I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this —�
permit Is issued' 9 �OU Seismic 1�
❑ have and will I Porf Worker's Compensation Insurance,as required by Section 3700's / / 7 / a
f the Labor Code,for a pertor ands of ih ork for which This permit b Issued.My Worker's
Compensation r lice carr and Pol' number are' Total
Carrier / �J r G� Policy No. S PERMITAUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.p ( f�
(This section need not be completed If the permit Is for one hundred callare($100)or less.) _
I certify that In the performance of the work for which this permit Is IssuefiI shall not employ
any person In any manner so as to become subject to the Workers'Camper aation Laws of call- All roofs shall be inspected prior t0 any roofirig material being
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become A I' lit u erstands 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. SO ce regul tions.
I certify that I have read this application and state that the above Information"C'
s correct I agree
to comply with all city and county ordinances and state laws relating to building construction,antl roof e n to class r tter.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spection purposes. /y[/
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may In any way accrue against said City in consequence Sill GNATU F
MPRAP LICANT 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY