R-5730 PERMIT5730
_J APPLICATION FOR CITY OF CUPERTINO NUMBER R�
REROOF PERMIT INSPECTION DIVISION PERMIT PERMIT WORK IS
NOT STARTED
(408)777-3228 WITHIN 80PDAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS q T
RESIDENTIAL COMMERCIAL OTHER
HAZARDOUS FIRE AREA
OWNEp;,S
O\� (7nYES ❑ If yes—I understand that a Class A
NAME PC U NO
mof assembly is required
LC.B.O.k
EXISTING ROOF COVERING
ADDRESS /
NUMBER OF EXISTING COVERINGS
PHONE
CON RACTOR'S TO BE REMOVED TO BE RETAINED
NAME , -KPE OFR OF VERIN
ADDRESS _�_ '
CITY&ZIP 1 S�9 ,33 EXISTING
PHONE
� BUILT-UP ROOF ❑
LICENSE 7 ASPHALT SHINGLES ❑
NUMBER I
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing sale OOD SHAKES
7000)of Division 3 of the Business and Professions Cotle,and my license Is in lu orce tl
effect. \/' 3 WOOD SHINGLES P A J e
License Class `-� Llc.Number ' � � ❑
1 OTHER(SPECIFY}yo
Data -iqq w Contractor {{�� V 18 rL7f
OWNER-BUILDER LARATI N PROPOSED
I hereby affirm that I em exempt from the Contractor's License Law for the following reason. ary
(Sao.7031.5,Business and Professions Cotle: Any city or county which requires a permit to BUILT-UP ROOF OF L t�'�
construct alter.improve.demolish,or repair any structure,prior to Its issuance.also regattas the I/f
applicant for such permit to file a signed statement that he is licensetl pursuant to the provisions
at the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 01 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).): WOOD SHAKES ❑
❑1,es owner of the property,or my employees with wages as their sole compensation,will do
the work,end the structure is not Intended or offered for safe(Sec.7044,Business and Protea
Bions Code:The Contractor's License Law does not apply to an owner of property who builds or
WOOD SHINGLES
rprovided that
improves thereon,and who does such work himself or through his own employees,
such improvements are not Intended or offered for sale.ll,however,the Wildingor Improvement OTHER(SPECIFY) ❑
Is sold within one year of completion,the owner-builder will have the burden of proving that he did
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 Coda:The Contractors License Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to en owner of property who builds or Improves thereon,and who contracts for such projects
with a contreclor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: l��i
❑1 have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, l' )a-
Building
as provided for by Section 37W o1 the Labor Code,for the performance of the work for which this ,f1 '
permit is Issued. {{a ( J\W '�' Seismic _
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
the Labor Code,for the performance of the w for which this permit is issued,My W'kg( Total
Compensation Insure co carrier P4 Policy nu at are: 1`d• v
carder Pailo) : PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed if the permit later 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
t
any person In any manner so as to become subject to the Workers'Compensation Laws of Call. All roofs shall nspeCled prior to any roofing material Deng
fornia. r r installed. If a roof is installed without first obtaining an
Date I t I Applloanl inspection,I agree to remove all new materials for inspection.
NOTI TO APPLI ANT: If,after making thili Certificate of Exemption,you should become Applicant understands and will Comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply
with such provisions or this permit shall be deemed revoked. SOUfCe regulations.
I certify that I have read this application and state that the above Information Is correct.I agree All root coverings to be class"C"or better.
to hereby authorize
rep and se county ordinances and ter upon
the
to build ng construction,tlyf and g 1 I ���
hereby comply
with
hlze representatives of this city to enter upon the above build oneo property for In- s Il 1/
spectlon purposes.
lq
(We)agree to savo,Indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may In any way accrue against said City in consequence SIGNATURE OF APPLICANT DATE
of the granting al ihle permit.
. 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 -