R 5558 APPLICATION FOR CITY OF CUPERTINO
NUMBER PERMIT
R- 5558
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS '•nom-✓ 1//� . '
/d l/ lJ RESIDENTIAL COMMERCIAL OTHER
OWNER'S I HAZARDOUS FIRE AREA
YES ❑ If yes-I understand that a Class A
NAME— of assembly is required.
NO Initial I.C.B.O.W
ADDRESS SQ/YYti� EXISTING ROOF COVERING
PHONE 47 IF " � O O
NUMBER OF EXISTING COVERINGS 71
�
CONTRA 'S
TO BE REMOVED Z+ TO BE RETAINED
NAME
ADDRESS /0`4C
/J 0 �H TYPE OF ROOF COVERING
CITY&ZIP 7•S V 1Gi�ri 1."?NLn I
. . 9 30 EXISTING
PHONEANO, 45 3 - 6 3 Z 3 BUILT-UP ROOF ❑
CENSE
NUMBER D 2- -I O b ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license le In full force and
ellect' WOOD SHINGLES
LlcenseChys �, 3 9 Llc.Number
3 19� OTHER(SPECIFY) A I IJ ElOete Contractor
OWNER-BUILDER DE;l_ARATICAPROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason. R(jpe '1•6 g ANSI(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to 61110 R
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 S(commencing with Section 7000)of Division 3 of the CI�y UF L,UF'Cn l IIV
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES e4^+-+c
y(L 6A'P6
exemption.Any violatlon of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500).):
01,as owner of the 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 Profes.
sions Code: The Contractors License Lew 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.It,however,the building or Improvement
is soId within one year of completlon,the owner-bullder will have the burden of proving that he did OTHER(SPECIFY)
not build or Improve for purpose of sale.). /—_
01,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(See.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(()licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
E]I am exempt under Sec. ,B B P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT.FEE
I hereby affirm under penalty of perjury one of the following declaration; 1
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Building \V.
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this 3/ U[/ U
per t Is Issued.. !
I have antl will maintain Worker's Compensation Insurance,a(required by Section 3700 of V` r 7, SBISRIIC
t bor Code,for the performance of the work for which this permit Is Issued.My Worker's
Compensetron Ineu ce carrier entl Policy number are: Total
Carrier_ � �t-"k Policy Nos 71-07-17 S PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N,C.O
(This section need not be completed If the permit Is for one hundred dollars($100)or lase.)
1 certify that In the performance of the work for which this permit Is Issued,I(heli not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Cell. All roofs shaR be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date �15 V Applicant B f inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,shot making this Certificate o Exemption,you should become Applicant understands and will
subject to the Workers'Compensation provisions of the Lebo Code,you must forthwith comply PP comply P y with all non point
with such provision?or this permit$hell be deemed revoked. source regulations.
I certify that l have read this application and state that the above Information is correct l 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 to enter upon the above-mentioned property for In.
spection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against IabIIKIes, r
judgments,costs and expenses which may In any way accrue against said City In consequence SIASU OF APPLICANT /A `
of the granting of this permit.
PRE-INSPECTION: - PLYWOOD: IN-PROGRESS:
INSP. DATE INSP—DATE— INSR - 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