R 5496 APPLICATION FOR CITY OF CUPERTINO PERMIT
R- 5496
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-.3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
�I 180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
10070 (`j. L//,D RESIDENTIAL �MMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME �/31U oof assembly Is required.
N Initial I.C.B.O.8
ADDRESS S AMS EXISTING ROOF COVERING
PHONE eZ " 3 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S /J
NAME 405 677,4 D/dS /D p0/r/ TO BE REMOVED TO BE RETAINED
ADDRESS /� TYPE OF ROOF COVERING
CITY&ZIP /�• O - Aek /726 I-as C*- EXISTING
i
PHONE ���� /2,T ? BUILT-UP ROOF ❑��`j/
NUMBER — ASPHALT SHINGLES ❑ ! ��
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions 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
anent. WOOD SHINGLES ❑
License Class L 3 � Lic.Number T/'r�
Data 9b Contractor l-C1,SOTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that 1 em 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,sitar,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 Lew(Chapter s(rnmmeneing with Section 7000)of Dlvlsion 3 of rho �J
• Business and Professions Code)or that he Is exempt II emfmm 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).):
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ®�C - 3 c ®
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes- 3
sions Code;The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES II--II
improves thereon,and who does such work himself or through his own employees,provided that I� IJ.f IN0
such improvements are not Intended or offered for sale.If,however,the building or improvement /x'TM Vf VUrt
is aoto within one year of completion,the owner-builder will have the burden of proving that he did CTHER(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(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 contractors)licensed pursuant to the Contractor's License Law, PROVIDE MFGR.INSTALLATION SPECS.
❑I em exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICA I TE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration; ex
❑I have and will maintain a Certificate of Consent to selbinsurs for Workers Compensation, Buildingas provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit Is Issued. vy r�
I:]I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of f'Tr Vh (vUrCk f INCSeismic
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's
Compensation Insurance carrier and Policy number are: Total
Carrier /"—,*1, 1--e /P Policy No-�/�/7�//?7S71 PERMIT AUTHOR TION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.00
(This section need not be completed If the permit Is for one hundred dollars($100)or leas.)
I certify that In the performance of the work for which this permit Is Issued,I Shell not emloy
any person In any manner so as to become subject tot Workers'Ccmpensetion Laws of&II. All roofs shall be inspected prior to any roofing material being
f°`nla. installed. If a roof is installed without first obtaining an
Date/ 2-4 7 Applicant inspection,I agree to remove all new materials for inspection.
NOT CE TO APPLICANT: It,alter making this Certificate of -xOMPIP ,you should become
I
subject o 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 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 roof coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
speclion purposes. —
(We)agree to save,Indemnify and keep harmless the City of Cupertino aSher habIIBles,
judgments,costs and expenses which may In any way accrue against said City?,,consequence
at granting mthis Parma. SIGN)TURF OF APPLIGANT 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