R 5727 APPLICATION FOR CITY OF CUPERTINO
NIUMBERR— 5727
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 )I
" V�0I ri I V
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes-I understand that a Class A
NAME 1 ` rl� 1 G y�Q�J tool assembly is required.
6.
N Initial I.C.B.O.M
ADDRESS w EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACT R'S - ^y
- 1J{� TO BE REMOVED TO BE RETAINED
NAME
ADDRESS 2r-7_/� I 1�I __ Y (J d (�`� TYPE OF ROOF COVERING
CITU 8 ZIP- 32-7-A(1 Ll, YIA, �C 1
EXISTING
PHONE 408 -q7J1__7?SS BUILT-UP ROOF - ❑ -
LICENSE
NUMBER , ASPHALT SHINGLES ❑'
LICENSED CONTRACTORS DECLARATION `
I hereby affirm that I am licensed under provisions of Chapter S(commencing with Section WOOD SHAKES XRYS
q/771 7
7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and
sneer. _ WOOD SHINGLES
Da ❑
Licensecas Lic.Number -
te Contractor
OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION ROPOSED
1 hereby affirm that I am exempt from the Contractor's License or the b owl g
(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 KN'41
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($500).): WOOD SHAKES
C]1,as owner of the property,or my employees with wages as their sole compensation,will do ❑
the work,and the structure Is not Intended or offered for sale(Sac.7044,Business and Profile.
sums Code:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑
improves thereon,and who does such work himself or through his own employees,provided that
such improvements are not Intended or offered for sale.If,however,the building or Improvement
Is sold within one year of completion,the owner-bullder will have the burden of proving that he did OTHER(SPECIFY) El
build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(a)licensed pursuant to the Contractor's License Law. PROVIDE MFG R.INSTALLATION SPECS.
El am exempt under Sec. ,B$P.C.for this reason
Owner Date APPLI T O TE VALUATION P IT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the fallowing declaration: D I /�
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation,
permiis issued. BUII Ing /l
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this ®l7 6 ��
b4lt have 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 Workers Total
Compensation Insurance carrier an ell number are: /�]� /_ CIN Or 1zUf L"ISI h..
Carrier Arnpnrn�� Policy No.�D7690 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.Q
(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 w ch this permit Is Issued,I shall not employ
any person In any manner so as to become su lea the We a pensenon Laws of call. All roofs shall la inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date //-li, . Applicant 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 Dint
subject to the Workers'Compensation provisions of the Labor Cade,you must lanhwl(h comply pP• P Y P
with such provisions or this permit shelQ be deemed revoked. source r gulations.
1 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 state laws relating to building con struction,and All of overin S obe class"C°Of better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilitiesand exens ,
-
ofthe g eis
in nting of this
pePm1 ee which may In any way accrue against ealtl City In consequence SIG ATURE 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 -