R-5705 (2) I�
APPLICATION FOR CITY OF CUPERTINO
NUMB PERMIR R- 5705
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 A/Df/D]RREESSS,���/lly�y���,, (� j�
• ✓u� iNAZFdWo�l' A"IE RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
AC�' �`�� YES ❑ If yes-I understand that a Class A
NAME VVV roof assembly is required.
r NO In18al I.C.B.O.IX
ADDRESS 892 .AZ
t3L4LIn_( Wo=cV EXISTING ROOF COVERING
PHONE L;3— NUMBER OF EXISTING COVERINGS y
CONTRACTOR'S
I llLLit�f TO BE REMOVED eS TO BE RETAINED
NAME w
C
ADDRESS P 1 13 1 if L,st-5 Ohcl AS(..l ek "`� TYPE OF ROOF COVERING
! EXISTING
PHONE 2�a-5('-o BUILT-UP ROOFLICENSE
❑
NUMBER T9'1o99 - ASPHALTSHINGLES
LICENSED CONTRACTORS DECLARATION / �p
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES El
]000)of Division 3 of the Business and Professions Code,and my license Is in full force and
effect' ,I WOOD SHINGLES ❑
License Class ` 3 Lid.NumberT7 Y°y
Data (Z 9 97 contractor S OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby aHitm that I am exempt from the Contractor's License Law for the following reason.
(Sac.7031.5,Business and Professions Code; Any city or county which requires a permit to
construct,altar,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF Elapplicant for such permit to file 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 V ��
Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES u l
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than live hundred dollars(S500).):
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 Proles-
slons Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES E]Improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not intended or off Steel for sale.It,however,the building or improvement
Is sold within one year 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 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 for such projects
with a contractor(s)ncensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
E]I am exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: ^
Q l have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, � ' D Building O�'
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this ��/�
permit is issued. C.f71 Seismic `o`er
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of {vI 9 jill.,
the Labor Code,for the performance of the work for which this permit Is issued.My Worker's yxl� I�rI Total
-Compensation Insurance carrier and Policyre
number a : �y Y U
Carrier 'it-Alt F"'A 4 Policy No. (7 g7 36� —IF7 F5E1amur(,AUTHO I ION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(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 employ
any person in any manner so as to become subject to the rkers Compnsatron Law.of car. All roofs shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date I 1IqI17 Applicant inspection,I agree to remove all new materials for inspection.
NOTICE subject to the Workers'Compensation n provisions ofatheticate of Laborr Code,Exemption,
must forthwitbecome
h comply Applicant understands and will comply with all non point
with such provisions or this permit shalQbe deemed revoked. BDDrCe 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 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. !-��
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, J�
judgments,coats and expenses which may in any way accrue against said City in consequence SIGNATURE OF APPLICANT DATE
of the granting of this 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY