R 5959 PERMIT R_ 5959
APPLICATION FOR CITY OF CUPERTINO NUMBER .
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
S / ^ a O8 777-.3`228 PERMIT EXPIRES IF WORK IS NOT STARTED
6 G �J WITHIN 180 DAYS OF PERMIT ISSUANCE OR
• _ 180 DAYS FROM LASTCALLED INSPECTION.
BUILDING ADDRESS �f
W RESIDENTIAL COMMERCIAL OTHER
-
OWNER'S_ HAZARDOUS FIRE AREA
74CS [:] If yes-I understand that a Class A
NAME S r1 roof assembly is required. -
j L NO ❑ Initial I.C.B.O.B
ADDRESS p p e/"S / EXISTING ROOF COVERING
PHONE , OQ / S^ NUMBER OF EXISTING COVERINGS J
CONTRACTOR'S �
NAME ��� as - DOr/i7 a TO BE REMOVED TO BE RETAINED
ADDRESS RQ �/ / f//' L O �g ftp TYPE OF ROOF COVERING
CITY B ZIP -A_/L�1( I ' rJ.Etgy; '
EXISTING
PHONE - �I(J ��O ����2.� BUILT-UP ROOF ❑
LICENSE
NUMBERASPHALTSHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license is In lu force an -
effect. ///JJJ O /�a OOD SHINGLES ❑
License Class Llc.Number
Data Contractor
THER(SPECIFY) ElOWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's,License Low for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to -
construct,alter,Improve,demolish,or repair any structure,prior to its Issuance,also require.the BV
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(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 E]exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
ID 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
the work,and the structure Is not intended or offered for sale(Sec.7044,Business and Profes. S
slons 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 !\�� \\\Vv
is ac id within one year of completion,the ownar-bullder will have the burden of proving that he did HER(SPECIFY) uC�s
not build or Improve for purpose of sale.). T V
C]I,as owner of the property,am exclusively contracting with licensed contractor;to construct l)
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 a rr
with a contractor(s)licensed pursuant to the Contractor's license Lew. PROVIDE MFGR.INSTALLATION SPECS
.4 exempt under ntler Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: ca
(31 have and will maintain a Certificate of Consent to.elbinsure for Worker's Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this Q
permit is issued, 1 sa
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of - 1 /yam, Seismic
the Labor Code,for the performance of work for which this,permit Is Issued.My Worker. *1 / /D� �a�/O •p
CompenseI nInsurance carrier andP nu be Total O
Carl olicy No.- ,k•u �f�
PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROMWORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed if the permit Is for one hundred dollars($100)or less.)
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 Cali. 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,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 sholP.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 root Ings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costa and expenses which may In any way accrue against said City in consequence SIGNA URE OF PLI A T DATE
of the granting of this permit.
• PRE.NSPECTION. PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY