R 5920 (2) PERMIT R_ 5920
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT g SS R 1408)777.3228 PERMIT EXPIRES IF WORK IS NOT STARTED
f WITHIN 180 DAYS OF PERMIT ISSUANCE OR
r 180 DAYS FROM LAST CALLED INSPECTION.
. BUILDING ADDRESS //YJ Q•
OI 4 d o, �J S RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
l^' :
VES E] If yes—I understand that a Class A
NAME S � J Lei Q roof a55embly is required.
NO ❑ Initial I.C.B.O.It
ADDRESS /' EXISTING ROOF COVERING
PHONE S NUMBER OF EXISTING COVERINGS
CONTRACT 'S.
NAME O 'T O (;h TO BE REMOVED TO BE RETAINED
ADDRESS C q TYPE OF ROOF COVERING .
CITY&ZIP . C O G ..S Sd
EXISTING c
PHONE yaR' 3SB'-�2 3"3 BUILT-UP ROOF ❑
LICENSE El
ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed antler provisions of Chapter g(commencing with Section WOOD SHAKES
i
7000)of Division 3 of the Business and Professions Code,and my license e in In lull lona and
effect. !�j�f//' �j WOOD SHINGLES El
License Class . Lie.Number ff 3�/
Data Contractor
OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the fallowing reason.
(See.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,aller,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.License Law(Chapter 0(commencing with Section 7000)of Division 3 of the El 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
e civil penalty owner
not more men titre by dredemployees
dollyeesre th wages
age: WOOD SHAKES
❑Irks ownersthe cture moot tended oyeeered wagesas(Sec.their solo compensation,snPrllls- pI-io
the work,and me onmture la not intended or offered for Bale(Sea owner
of Business and Prole a- H
cions Code:The,an who
Licence Law does not lforthapply throuo an gh
own
property who provided
WOOD SHINGLES ❑
lds Of
Improves thereon,and who tloensuch work himself et through hie own employees,provided that
such improvementsaro not Intended thoffered
wnerfor edea.ill however,the building or gthat he d3U 1 ' ( ) ❑
n sold tbuildwithinor
pr yearfor purpose
sthe owner-builder will have the burden of proving that hatl 1 +� +l-Ir 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 Contractors License Law doe�liq T V• vw'PROVfb5 I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such prol&b
with aa mexempt P.licensed pursuant to me Contractors license Lew. PROVIDE MFGR.INSTALLATION SPECS. /10
❑I em exempt antler Sec. ,B 8 C.for tole reason
Owner Dela
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: o0
01 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Building
as provided for by Section 3700 of 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 r// Seismic '
the Labor Code,for the performance of the work for which this permit is Issued.My Workers
� PQS�JC O gj
0
Compenlo4carinuTotal yp•
7ACarrier Policy
PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.Q _ p
(This section need not be completed If the permit Is for one hundred dollars($100)or leas.)
I certify that In the performance of the work for which this permit Is Issued,I shall not employ R-
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 roofing material being
forma. installed. If a roof is installed without first obtaining an
Dale Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and will cora
subject to the Workers'Compensation provisions of the Labor Cotler you must forthwith comply pP ply with all non point
with such provisions or this permit shall be doomed 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 stale laws relating to building construction,and All roof. rngs tc be �ior better.
hereby authorize representallvee of this city to enter upon the above-mentioned property for In.
spemion purposes.
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities, t
judgments,costs and expenses which may In any way accrue against said City in consequence
• of me granting of this permit. SIGr4ATuRE OF 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY