R-5484 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R" 5 484
s
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
1 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
io 209 eAPiti4%-W /; p_ ,/
1Na D Y RESIDENTIAL COMMERCIAL OTHER -
OWNER'S --� HAZARDOUS FIRE AREA
NAME -2V14 V 7_,9_A Ala 77 E s�c�tA�t/
YES ❑ If yes assembly is required..I understand that Class A
roof as
NO Initial I.C.B.O.p
ADDRESS E A-S fl-d0 Yr EXISTING ROOF COVERING
PHONE a - s's- a 3 NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED _llNAME
ADDRESS TYPE OF ROOF COVERING
CITYa ZIP EXISTING
PHO
PHONE BUILT-UP ROOF
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license is in full force and
effect.
WOOD SHINGLES
License Class Lic.Number
Date Contractor
OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(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 PAID ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Law(Chapter B(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHIN 9N • 3 rftiY[r'a�
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to i¢4
e civil penalty of not more than five hundred dollars($500).): WOOD SHAKES
L]1,as owner of the property,or my employees with wages as their sole compensation,will do y�7 1y
the work,and the structure is not intended or offered for sale(Sec.7044,Business and Protes- CITY i OF CUPr'ERTl
$ions 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.If,however,the building or Improvement
is sold within one year of completion,the owner-butlder will have the burden of proving that he did OTHER(SPECIFY)
not build or Improve ler purpose of sale.).
❑I,as owner of the Property,am exclusively contracting with licensed contractors to construct l �•
the project(Sec.7044,Business and Professions Code:The Contractor's 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 contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE Ili INSTALLATION SPECS.
❑I am exempt under Sec. ,B 8 P.C.for this reason
owner "" - - Date -' APPLICATION DATE VALUATIONrBuilding
RMIT FEE
ORKER'S COMPENSATION DE=RA
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation,asprovidedforbySection3700oftheLaborCode,for the performance of the work for which this1permit is Issued. 3' Dd ' c❑1 have antl will maintain Worker's Compensation Insurance,as required by Section 3700 ofthe Labor Cotle,for the performance of the work for which this permit Is issued.My Worker's rCompensation Insurance carrier antl Policy number are:Carrier Policy No. PERMIT AUTHORIZATIONDATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.]
(This section need not be completed It the permit is for one hundred dollars($100)or lass.)
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 Workers'Compensation Laws of Cell- All roofs shall be Inspected prior to any ribotintf 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: If,after making this Certificate of Exemption,you should become A titan[ understands and will tom I with all non dint
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP P y P
with such provisions or this permit shall be deemed 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 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)agreesave,Indemnity and keep harmless the City of Cupertino against liabilities,
judgments.costss I and expenses which may n any way accrue epelnsl said City In consequenceGN TUR F PLICANT 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