R 5195 PERMIT R_ 5195
APPLICATION FOR CITY OF CUPERTINO NUMBER
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 e
RES]DENTI COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME �) - roof assembly is required
NO 9_} Initial I.C.B.O.It
ADDRESS
EXISTING ROOF COVERING
/
v PHONE ' NUMBER OF EXISTING COVERINGS
CONTRACTO '
• TO BE REMOVED � TO BE RETAINED
NAME
ADDRESS .r/ TYPE OF ROOF COVERING
CITY S ZIP A EXISTING.
PHONE as _ 2– 2 BUILT-UP ROOFLICENSE
❑
NUMBER Z2 3 ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION /
hereby that l em licensed under provisions of Chapter B(commencing with Section WOOD SHAKES Lr Jo/
7000)of Division inion 3 of the Business and Professions Code,and my license Is In lull force and
effect.
WOOD SHINGLES ❑
License Claes Lic.Num at �—
Date 0` 15 (D o,\:✓. OTHER (SPECIFY) [ A 4 1)
f Contractor "��
OWNER-BUILDER DECLARATION PROPOSED
I hereby alllrm that I am exempt from the Contractor's License Law for the following reason. rl ��
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to 4
construct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF
applicant for such permit to Ole a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the CITY (.JI- VVYCr51 IIVU
. Business and Professions Coda)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES u
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of not more than five hundred dollars($500).):
ED 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 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.It,however,the building or Improvement _
Is sold within one yes r 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 Lew 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.
❑I em exempt under Sec. a&P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to selMnsure for Worker's Compensation, Building/z7'
h
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this / /
permit to Issued. �`'y I SeismicO
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
Fl
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's
'Compone 'n Insurance ruler and Policy number are: I Total /27
Ae
^
Carder Policy NQtJ! �-� 3 S PER AUTHORIZATION DATE
CERTIFICATE 3F EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0 /f
(This section need not be completed If the permit Is for one hundred dollars($100)or lase.)
1 certify that In the performance of the work for which Nle permit is Issued,I shall not employ
any.person In any manner so as to become subject to the Workers'Compens1ation Laws of Cell. All roots s I e inspected prior to any roofing material being
f°`ni°' 1y, jnstalle If a roof is installed without first obtaining an
Date Appy 3 inspec n,I agree to remove all new materials for inspection.
NOTIC T PPUCANT: Il,after making.his e n icate 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 shal0be deemed revoked. source regulations.
I certify that I have read this application and slate 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 coverings to be class"C"Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spection purposes. —yJ\
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, CTh-V r //JL
judgments,costs and expenses which may in any way accrue against sold CIN In consequence ' /—y
. of the granting of this Permit. SIGNAT R OF APPLICANT A E
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