R 5721 APPLICATION FOR CITY OF CUPERTINO
NUMBPERER R- 5 7 21
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777.3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
1S0 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
g00 ,570 /�+te
(/ RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA '
,/ .//- /� � �. VES ❑ If s-I understand that a Class A
NAME �1 assembly is required.
fir % N Initial I.C.B.O.N
ADDRESS—35o -Arn 7 r €XISTING ROOF COVERING
PHONE b5O— -I /J NUM ER OF EXISTING COVERINGS /
CONTRACTOR'
Sf
N � �o��iM� TO BE EMOVED
AME / TO BE RETAINED
ADDRESS . 12V- ✓1 /�� /_��X. y'_/ 'CT' TYPE OF ROOF COVERING
CITY&ZIP t�1J / t/1H (il. .YJ�r-� /Lal V J EXISTING .
PHONE 7o`k7- 1 7�-75 �J BUILT-UP ROOF ❑
NUMBER Y/771`7 717 ASPHALT SHINGLES
- LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 em licensed under provislons of Chapter B(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license is in full force and
affect. (q' .2 c/ WOOD SHINGLES ❑
Llcene'/Glees� Llc.Number /
Data'I"7x�-'97 Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Lew for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
constructeller,Improve,demolish,or repair any structure,prior to its issuance,also requires the BUILT-UP ROOF El
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
e civil penalty of not more than five hundred dollars($500).): WOOD SHAKES
❑I,as owner of the property,or my employees with wages as their sole compensation,will do ❑
the work,and the structure is not Intended or offered for sale(See.7044,Business and Profss-
sions Code:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑
Improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for sale.If,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not bul id or Improve for purpose of sale.). '�
❑I,as owner of the property,em exclusively contracting with licensed 6nuactom to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improve$thereon,and who contracts for such projects
with a contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
El am exempt under Sec. ,B 8 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATEI VALUATION .0_,ff@1fIffT FEE
I hereby affirm under penalty of perjury one of the follow]ng declaration: D
EIIt
have and will maintain a Certificate of Consent to self-insure for Workers Compensation, P {� BUIi Ing
es provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is Issued. - p�7� $elSfnlC
❑I have and will maintain Workers Compensation Insurance,as required by Section 3700 of ••o�,a
_the Labor Code,for the performance of the work for which this permit Is Issued.7My Workers Al d
Compensa ; o Zer grldpellpy nym rare Policy No. 0 n /�� Tota
Carrier YJ�f�r- ff�M H IZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N C
(This section need not be completed if the permit is for one hundred dollars($100)or less.)
1 certify that In the performance al the work lar w ch this per sued,I shall not employ
any person In any manner so as to become a ject the Wor s Co nation Laws of Call- All roots Sh beiEso&tecl prior to any roofing mat rial being
fornia. installed. if a roof is installed without first obtaining an
Dale Applicen 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 point
sub;ect to the Workers'Compensation provisions of to Labor Code,you must forthwith comply PP P y p
with such provisions or this permit shelllbs deemed revoked. source re ulatl ons.
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 Of vert Class"C"Or better.
hereby authorize representatives of this city to enter upon the above-mentloned property for In-
spection purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may In any way accrue against said City In consequence
• of the granting of this permit. SIGNATURE 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