R 5070 PERMIT R_ 5070
APPLICATION FOR CITY of CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
' WITHIN DAYS PERMIT ISSUANCE OR
1 DANSS FROM LAST CALLED INSPECTION.•
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
VES Elf yes—I.understand that a Class A
NAME roof assembly is required.
, ^ n N C Initial I.C.B.O.#
ADDRESS 2.�2 s(l.t�-' dC�� a-c...�P� EXISTING ROOF COVERING
•• PHONE
I L•( NU BER OF EXISTING COVERINGS '
CONTRA TOR'S -
NAME iL[5 se✓I Q'J IAC TO BE REMOVED TO BE RETAINED
ADDRESS Z2 2 ^- /T / LUPE OF ROOF COVERING
CITY&ZIP C'ML&
o� EXISTING
�
PHONE q �� `� BUILT-UP ROOF
LICENSE
NUMBER 459 --?3L ASPHALT SHINGLES El
LICENSED CONTRACTORS DECLARATION �/
I hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES v/I
7000)of Division 3 of the Business and Professions Code,and my license to In full force and >
effect.
r— WOOD SHINGLES ❑-,
License Of - Uo.Nurr a v r• '
OTHER(SPECIFY) ! ❑
Conbac
OW from th ContrffRactors
DECLARATION PROPOSED uG1 s AS*
I hereby affirm that am exempt from the e: Any city Llcenee Lew for the following anis t.
(Sac.7031.5,Business end Professions Code: Any clry 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 ❑ t 11'w
applicant for such permit to 1119 a signed statement that he Is licensed pursuant to the provisions
' of the Contractor's License Law(Chapter a(commenclnp with Section 7000)of Division 3 of the t U`
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES "`1 ❑
exemption.Any violation of Section 7031.5 by any applicant for s permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500).):
❑1,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•
alone Code:The Contractors 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, rovlded that ❑
ouch Improvements are not Intended or offered for sale.If,however,the building or Pmprovement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) El
build or Improve for purpose of sale.).
❑I,as owner of the property,em 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 far such projects
with a contractor(s)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,S 6 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERIV
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to sell-Insure for Workers Compeneatlon, it
ee provided for by Section 3700 of the Labor Code,for teperformance of the work lorwhlch this r{'s 1)� /�� ,rx�/tD r/'1tj
AgrlyHs I98Yed. �(}f[I/I ll/ tu( (/ `/ smlc
heve antl will maintain Worker's Compensation Insurance,as required by Section 3700 of
e or Code,for the performance of the work for which this permit Is Issued.My Worker's
'• Compensation Insurance carrier and P licy number are: C Total
CarrierPolicy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
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 amtoy
any person In any manner so as to become subject to the Workers'Compensation Laws of nml. All roofs shatrbOgnspected prior to any roofing aterial being
forma. installed. If a roof is installed without first obtaining an
Dote Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO subject to the Work no'Compei,after nsatlon provisionls of theflcate of Laborr Code,you mustforthwith lbecome
comply Applicant understands and will comply with all non point
with such provisions or this permit shall be doomed revoked, source regulations.
I certify that I have read this application and state that the above Information l9 correct,I agree
to comply with all city and county Ord rances and state laws rotating to building construction,and AllrSlOf-CCY� n e "C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for Int ter/
spoction purposes.
IWe)agree to save, Indemnify and keep harmless the City of Cupertino against liabilities,
• oltg9 granontoticostsng al ihl9 pePmij ea which they In any way accrue against said City gn consequence SI TORE OF APPLICANT D
ATE
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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY