R 5362 APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 5362
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
IBe DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S - HAZARDOUS FIRE REA
VES ❑ If yes—I understand that a'Class A
NAME e I, C_ roof assembly is required.
NO Initial I.C.B.O.It
ADDRESS EXISTING ROOF COVERING
PHONE — —( 7 •-- NUMBER OF EXISTING COVERINGS
CONTRACTOR'S ,
NAME E.S �Y TO BE REMOVED———�Z —TO BE RETAINED
ADDRESS3 I tF C-� y,�-�� TYPE OF ROOF COVERING
CITY&ZIP s' EXISTING
PHONE ry d J b D / I BUILT-UP ROOF ❑
NUMBER - ASPHALT SHINGLES Roe
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter B(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license la In full force end
effect. Q WOOD SHINGLES ❑
License Class Llc.Number / �l
Data
'7 - ContractoOTHER(SPECT ❑
r � ('
OWNER-BUILDER DECLARATION Q $bac ('y✓?, PROPOSED
1 hereby affirm that I em exempt from the Contractors License Law for the following r on.
(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 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 Lew(Chapter a(commenclnpp with Section 7000)of Division 3 of the
Business and Professions Code)or that he Is exempt Iharefrom 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 sole compensation,will do WOOD SHAKES
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes-
Siena Code:The Contractors License Lew 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.It,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,Business 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
with a contractors)licensed pursuant to the Contractors License Lew. PROVIDE MFGR.INSTALLATION SPECS.
C]1 am exempt under Sec. ,B&P.C.Mr this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLIqAJIW DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent or to sell-Insure performa for Workers Compensation,which
this Building I
pe mit is Is for by Section 3700 of the Labor Code,for the performance of the work for which ihlb �� 17 rt'1 V 77W
permit le Issued. 700 Of F Q Nrytl S61Sn11C
❑I neve and will maintain Workers f the work
which this as requiredsu Section Worker's the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's
CompensallPPn Insurance�p`eerrl end Policy number are: �/ I - t/ur Ck I INU Total
Carrier_ LCa;;iso It)Q� L Policy N,124 /�SS—� PERMIT AUTHORIZATIONDATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.D
(This section need not be completed It the permit Is for one hundred dollars I$100)or less)
I certify that in the performance of the work for which this permit is Issued,I Shall not emptoy
any person In any manner so as to become subject to the Workers'Compensation Le Call. All roofs she be Icted prior to any roofing material being
fernia.ro' 'y installed. If a roof is installed without first obtaining an
Date `^ I 1 Applicant 2-) 8 2 (50 inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,shot making this Certificate of Exem n,you should become Applicant understands and will
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP comply p y with all non point
with such provisions or this permit Shell be doomed 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 A r00f ven be class'&better. .
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
erection purposes.
(We)agree to Save,Indemnify and keep harmless the City of Cupertino against liabilities, c/
judgments,costs and expenses which may In any way accrue against said City in consequence TURE OF APPLICANT ATE
of the granting o7 thisand permit. S
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