R 5196 PERMIT R_ 519 6
APPLICATION FOR CITY OFCUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
.
180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
wNER'S V HAZARDOUS FIRE AREA
IC,
n_ _ h S VES If yes—I understand that a Class
NAME I'y\ roof assembly is requited.
NO ❑ Initial I.C.B.O.k
ADDRESS PA /'1 Apj6bn EXISTING ROOF COVERING
•
PHONE + NUMBER OF EXISTING COVERINGS
CONTRA TOR'$ '
�� TO BE REMOVED TO BE RETAINED
NAME III��S
ADDRESSPE OF ROOF COVERING
�'^ 1 �_� M (�
CITY&ZIP TO�� �C�` �Y �l r
\ EXISTING
PHONE 217: } lKO BUILT-UP ROOFLICENSE
,
NUMBER �U-�d-v ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES ❑
700 0)of Division 3 of the Business and Professions Code,and my license is In full force and
effect.
]� WOOD SHINGLES ❑
License Clea Lic.Number c-(�6y
c OTHER(SPECIFY) ElDate Contractor ..
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors License Lew 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 Contractors License Law(Chapter a(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
a civil penalty of not more than five hundred dollars($500).):
C]1.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 Proles.
bons Code:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES
improves thereon,and who tloes 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 sold within one year of completion,the owner-builder will have the burden of proving that he old 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(Sac.7044,Business and Professions Code:The Contractor's Licence 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(s)licensed pursuant to the Contractors License Law. PROVIDE MFG R. INSTALLATION SPECS.
❑I am exempt under Sec. ,B&P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE1 VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration; ��
EI I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Sam Building '
as provided for by Section 3700 of the Labor Code.for the performance of the work for which this A 8
permit01 Is leaned. PO Seismic ��_
❑I have and will the performance
Workers Compensation Insurance,a9 required by Section Worker's'of s
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's
Compensation Insurance carrier and Policy number ere: �(�/ I Total
Carrier S � �J Policy No.!LfS—Ly����� PtFMMUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' /�y
COMPENSATION the ON INSURANCE 100)o CII F Ulu—
(This
V
' (TMs section need not be completed If the permit Is for one hundred dollars($100)or teas.)
I certify that In the performance of the work for which this permit Is Issued,I shell not employ
any person in any manner so as to become subject to the Workers'Compensation Laws of Cell. All roofs shat a inspected prior to any roofing material being
fornix. 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 became
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply Applicant understands and will comply 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 slate that the above Information Is correct.I agree
to comply with all city and county ordinances and elate laws relating to building construction,and All roof COVef gs to b class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for Iry
spection purposes. / /o/dhis
(We)agree to save,costs and expenses
and keep harmless the City of Cupertino against liabilities, !/
oche granting of this perrmiteea which may In any way accrue against said City In consequence I NATURE OFA LICANT 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 COPV