R 5963 APPLICATION FOR CITY OF CUPERTINO
NU BER- 5963
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
ER's �// / .HAZARDOUS FIRE AREA
NAME ��E � T'��+� �ES ❑ II yes s I understand That a Class A
roof assembly is required.
NO ❑ Initial I.C.B.O.p
ADDRESS (//) �7 EXISTING ROOF COVERING
PHONE 7 V ,1— NUMBER OF EXISTING COVERINGS
CONTRAC R'S
/�,, TO BE REMOVED- / TO BE RETAINED
NAME
ADOREssD 6X ���� � 4�-�� TYPE OF ROOF COVERING
CITV 8 ZIP (? EXISTING
PHONE + �r5 "/r9JS_� UILT-UP ROOF Cl
LICENSE
NUMBER PHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section W SHAKES
7000)of Division 3 of the Business and Professions Cotle,and my license Is in lull force and
effect. ([/�, WOOOV4. _. ❑
License Claes� Us.Number s",�1- �I`pl(9Lk.6'
Date Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED V
I hereby affirm that I am exempt from the Contractor's License Law for the to
reason.
(Sec,7031.5, Business and Professions Cada: 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 ❑ �L'
applicant for such permit to file a signed statement that he Ia licensed pursuant to the provisions `Q
at the Contractors License Law(Chapter 9(commoncing with Section 7000)of Division 3 of the ❑ �� VC
• Business and Profession.Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES 4
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to J
a civil penalty of not more than five hundred dollars($500).1:
❑l.as owner of the property,or my employees with wages as their sale compensation,will do WOOD SHAKES
the work,and the structure Is not Intended or aHerod for sale(Seo.7044,Business and Prolas- 7�
alone Code:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES
Improvesthereon,and who does such work himself or through his own employees,provided that ❑ �\
such Improvements are not intended or offered for sale.11,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 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,Buslnoss 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 a
with cont exempt under
Se pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS. f^
❑I em exempt untler Sec. ,B 8 P.C.for this meson f-(.�C4 fr-�
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
[3 1 have and will maintain a Certificate of Consent to seifdnsure for Workers Compensation, BUlldln
as provided for by Section 3700 of the Labor Code,Mr the performance of the work for which this Q g{—s--t--
permit Is issued.
C]I have and will maintain Workers Compensation Insurance,as required by Section 3700 of �I '101 -99)
1Q V 1 F/06Y 00 Seismic �`
„the Labor e,for the performance the work for which this permit Is Issued.My Workers f �j
Campsite n Inaurancecerrier t�n Icy umber re: Total T 0
CsmfI my NO. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0 rr�� q
(This section need not be completed if the permit is for one hundred dollars($100)or lase.) a r / 2 ,�9
I certify that In the performance of the work for which this permit is Issued,I shall not employ
any person in any manner so as to became subject to the Workers'Compensation Laws of Can- All roofs shall be inspected prior to any roofing material being
forma. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO'APPUCANT: If,atter making this Cedllieate of Exemption,you should become Applicant subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP understands and will comply with all non point
with such provisions or this permit shalCbe deemed revoked. source regulations.
certify that have reed 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 CO R gs to be Class nG.n Or better.
hereby authorize representatives of this city to enter upon the above-mentioned properly ler In. �
sp(We) purposes.
(We)agree s save,expenses
and keep harmless the City a of Cupertino against Ilebllillea,
ofthe gran,coats and expenses which they In any way accrue against said City In consequence
of 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