R 5261 PERMIT R_ 5 2 61
APPLICATION FOR CITY OF CUPERTINO NUMBER
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 ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OW R's HAZARDOUS FIRE AREA
YES ❑ 11 yes—I understand that a Class A
NA I • �I AIY�I TDY9 -. roof assembty is required.
—i I NO Initial I.C.B.O.ft
I ADDRE yI �p�C[�O lo� EXISTING ROOF COVERING
PHONE �Zf3— ZZ$S NUMBER OF EXISTING COVERINGS
k CONTRACT�Oj$JS,, y11�
NAME
1�^'SS•C 113,1 TO BE REMOVED TO BE RETAINED
���133..1
CrTYPE OF ROOF COV
vazla Lifol L4.JovL 6,C. ,��, 9n1� EXISTING
PHONE (r�0131 79Y- f1YOd BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES CLQ'
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing with Stroller,
7000) WOOD SHAKES 13of Division 3 of the Business and Professions Code,and my license le in lull force and
allow.
WOOD SHINGLES ❑
License Claes Lie.Number
Date Contreetor ^� OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
1 hereby affirm that I am 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,after,Improve,demolish,or repair anyctructure,prior to its Issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to Ilse 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 la exempt therefrom and the basis for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant fora 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 Proles-
sons Code:The Contractor's 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 o(completlon,the owner-builder will have the burden of proving that he did 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(Sec.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(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS,
❑1 am exempt under Sec. ,B 6 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:
❑I have and will maintain a Certificate of Consent to seildnaure for Worker's Compensation, P A 0 D BuII'In
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit Is Issued //1I��/ 1= Seismic
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of �57r 9
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's UU /Jy TOtflI
-the
Ins raansa lora d Policy number are: 1.
Carrier J TZ 1a� Policy No. ��� TIER.MtAI.JTih1-0RIZAT10N DATE
CERTIFICATE ofFROM WORKERS'
COMPENSATIONATION INSURANCE
RANCE N.C.O
(This section need not be completed If the permit Is for one hundred dollars($100)or lees.)
certify that In the performance of the work for which this permit Is Issued,I shall not emotoy
any person In any manner so as to become subject to the Workers'Compensation Laws of Ca11- All roofs shall a aspected prior to any roofing material being
tennis. installed. If a roof is installed without first obtaining an
1 Data Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become
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 shal0be 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 roofs Ings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
hereby
purposes. V
(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. IGNATURE OF APPLICANT DATE
PRE-INSPECTION: PLYWOOD: IIN-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