R 5962 ! r
APPLICATION FOR CITY OF CUPERTwo NUMBER R' 5962
.
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
• 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
Q RESIDENTIAL COMMERCIAL OTHER
OWNERS J- HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME JZMJ"i _ /�J/{7�I� J T(! roof assembly is required.
NO ❑ Initial I.C.B.O.q
ADDRESS. EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS /
CONTRARTOH'S - , -
TO BE REMOVED / TO BE RETAINED
NAME
ADDRESS EXISTING
. TYPE OF ROOF COVERING
CITY&ZIP ••
PHONE TD �� BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter S(commencing with SectionWOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license le In lull force and
D INGLES ❑
License Claes�:4.��. Llc.Number
Oats Contractor
OT (SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
1 hereby affirm that I am exempt from the Contractors License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,alter,improve,demollsh,or repair any structura,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 g(commando,with Section 70001 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
a civil penalty of not more than five hundred dollars($500),):
❑I,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 offered for sale(Sec.704,Business and Profes.
sions Code:The Contractor's License Law does not apply to an owner of property who bulldsor WOOD SHINGLES ❑
Improves thereon,and who does such work himself or through his own employees,provided that I
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 bulId or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct oo
the project(Sec.7044,Business and Professions Code:The Contractors License Lew does not PROVIDE I.C.B.O.R v. AStlarls
C
apply to an owner of property who builds or Improves thereon,and who contracts for such projects i/ •�etlrr�Y�
with a corticctor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS. `/��,
❑1 am exempt under Sec. ,B&P.C.for this reason 5 �.
rrlllly�
ip-
ownerData
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
hereby affirm under penalty of perjury one of the following sure for
g r y7,
❑ have and will maintain a Certificate of Consent to self-Insure for oftheWorker's Compensation,which
this Building
pe mit Is Is for by Section 3700 of the Labor Code,for the performance of the work for which this Q
permit la leaned. �'Lq /�J Seismic fill do
❑I have and will maintain Workerb Compensation Insurance,as required by Section 3700 0l /y
the Labor th
Coca,for the performane 1 e work for which this permit is Issued.My Workers
Compene n Insurance carrier e oolicY number sire: ��y Total /ill• Q
•Cerrj r��.�L1I/�Y•/i+i•-sKML.00pay l,14 �4 6 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 100)o r leas.) f' (This section need not be completed If the permit Is/or one hundred dollars($100)o
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 become subject to the Workers'Compensation Laws of Call- All roofs shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: if,alter making this Certificate of Exemption,you should become Applicant understands and will comply with all non slat
subject to the Workers'Compensation provisions of the Labor Cotle,you must forthwith comply PP p y p
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 co Ings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In- y�//�Ji��,� —•�
apache)purposes.
(We)agree to rive,expenses
and keep harmless the Clry ai Cupertino against liabilities,........
judgments,costa and expenaea which may In any way accrue against said City In consequence
• of the granting of this permit. SIGNATURE O APP ICANT 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