R 5907All
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COPY
NUMBER R- 5907
APPLICATION FOR CITY OF CUPERTINO
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(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
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RESIDENTIAL "` COMMERCIAL OTHER
OWNER'S
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HAZARDOUS FIRE AREA
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YES ❑ row- ungemlay that a ClassA
NAME lefa '
is nd
NO ❑ Initial I.C.B.O. 9 -
&or /a1/y � T
9S/$7
ADDRESS ,06, ✓aa 'Joxe
EXISTING ROOF COVERING
PHONE / 0b 97.3 -0623
NUMBER OF EXISTING COVERINGS
,
CONTRACTOR'S
101
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NAME Ae4l /Y e- ' - "071 1 p
TO BE REMOVED TO BE RETAINED
ADDRESS 0� �( �j /` ��� �Q ��•. 1
CITY azIP 14f� 0yk- dwi -{4 '/Gn j
TYPE OF ROOF COVERING
.
EXISTING
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PHONE / ^+%
BUILT-UP ROOF ❑
l
LICENSE �7
Sd7s/�
NUMBER
A$PHALTSHINGLES ❑
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 0 (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license Is In lull torte and
effect.
C �9 S"a7S'y_y
WOOD SHINGLES ❑
License Clens // Lic. Number
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OTHER (SPECIFY) ❑
Dale .� Contract
OWNER.BUILDbMTlI!CLARAT16N
I hereby affirm that I em exempt from the Contractor's License Law for the following reason.
PROPOSED
(Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to
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construct, alter. Improve, demolish. or repair any Structure, prior to Its Issuance, also requires the
BUILT-UP ROOF Ir ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
0f the Contractor's License Law (Chapter g (commencingg with Section 7000) of Division 3 of the
Business and Professions Code) or that he Is exempt I orelrom and the basis for the alleged
ASPHALT SHINGLESJUN ��rD
exemption. Any violation 01 SectlDn 7031.5 by any applicant for a permit subjects the applicant to
e 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 011'y yr vvr ��•..
the work, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Profes.
sions Code: The Contractor's License Lew does not apply to an owner of property who builds Or
Improves thereon, and who does such work himself or in rough his own employees, provided that
WOOD SHINGLES ❑
such Improvements are not Intended or offered for sale. If, 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 bulid or Improve for purpose of sole.).
❑ I, as owner of the property, am 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. U L 790
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 Law.
❑ 1 am exempt under Sec. ,B B P, C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner Dale
APPLICATION DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑ I have and will maintain a Certificate of Consent to sell -Insure for Worker's Compensation,
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Building/%�O
as provided for by Section 3700 o1 the Labor Code, for the performance of the work for which this
permit Is Issued.
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section 3700 of
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the Labor Code, for the performance of the work for which this permit is issued. My Workers
'Componsadon In ante Policy number are:
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Total
y/�ncesLc§�rrlef
- - ^ .J 1
/yR O" YO
PERMIT AUTHORIZATION
DATE
Carrier x " `- ' Policy No.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.]
be If the Is for hundred dollars less.)
(This section need not completed permit one ($100) or
I certify that In the performance of the work for which this permit Is Issued, I shell not employ
any parson In any manner so as to become subject to the Workers'Compensatlon 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: IL 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 tom
pp ply With all non point
with such provisions or this permit shelfbe deemed revoked.
Source regulations.
I certify that I have read this application and state that the above Information Is correct. I agree
tocomplylaws relating to building construction. and
•AII roof COVQ(In be C�a�SS "C" or better.
uwith rposlcityanticounryordinanceaantletele
hereby authorize representatives of this city t0 enter upon the above-mentioned property for In-
epectlon purposes.
'
(We) agree to Sava, indemnity and keep harmless the City of Cupertino against liabilities,
judgments, costa and expenses which may In any way accrue against said CityIn ---4---.
of the granting of this permit.
•''S��N%TUR F APPLICANT DATE
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
COPY