R 5509 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO
NUMBERR- 5509
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 '
CAl CR RESIDENTIAL _COMMERCIAL OTHER
OWNER'S - .HAZARDOUS FIRE AREA
YES ❑ Ilya —1 understand that a Class A '
NAME roof assembly Ls required.
NO ❑ Initial I.C.B.O.If
ADDRESS EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRAC
TOR'S
-r1 I f� '
NAME y-/0.'y k�t L TO BE REMOVED I TO BE RETAINED
ADDRESS / TYPE OF ROOF COVERING
CITY&ZIP L (A O t a r Jf s+. �4Vt Cr4-'2 Co
-
PHONE
Z EXISTING
PHONE ?S" BUILT-UP ROOF ❑
LICENSE —Z Z 3 3 - (r_gjR ASPHALT SHINGLES
NUMBER
LICENSED CONTRACTORS DECLARATION
I hereby atlrm that I em licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES ❑
7000)ofDivision 3 of the Business and Professions Cotle,and my license Is In full force and
affect. . WOOD SHINGLES ❑
License Class Lic.Number
OTHER(SPECIFY) ❑
Data Contractor
OWNER-BUILDER DECLARATION PROPOSED fC
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 11
applicant for such permit to fife a signed statement that he is licensed pursuant to the provisions C
• of the Contractors 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 SHINGLES 9Y
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❑I,as owner of the properly,or my employees with wages as their sole compensation,will do ❑
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Prefes-
slons 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
leadId within one year of completion,the ownenbullder 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 Coda:The Contractor's License Law does not PROVIDE LC.B.O, REPORT NO.
apply to an owner of property who builds or Improves thereon•and who contracts for such projects
with a contractor(e)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B&P.C.for this reason
Owner Data APPL Ad ATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the Ito self-insure
declaration:
for Wo \ '
❑f have and will maintain a of he Lab r Consent to Bali-Insure for Workers Compensation, Building
as pravltletl for by Section 3700 0l the labor Code,for the performance of the work for which this '
perm Is Issued. CP
have and w1II maintain Worker's Compensation Insurance,as refillred by Section 3700 of 01 Y U a' as(J/ Seismic
ill Labor Coda,for the performance of the work for which this permit is Issued.My Worker's F`U"c� Ll W�t 0 c' TOt81
Compensation,I,nfsurance carrier a Policy number are: E I
Carrier „1f'�Te Pu.etA Policy No.05- R7-iliio69 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(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 sit as to become subject to the Workers'Compensation Laws of Ceti- All roofs shall be inspect prior to any roofi g mate 'al being
forma. 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
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 ar this permit shalGbe 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 far In
spactlon purposes.
(We)aurae to save,Indemnity and keep harmless the City of Cupertino against Ilabllltles• /Vl`_'lsnv I 1/(/111 /�ix/•LJI/�"'✓V` r�_ ) p,�
ofthe granting at this peand rmit es which may In any way accrue against said City In consequence SIGNATURE OF APPLICANT DAT T
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