R 5854 (2) PERMIT R_ 5854
.
APPLICATION FOR CITY OF CUPERTINO NUMBER
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 LASTCALLED INSPECTION.
BUILDING ADDRESS
D I
`
RESIDENTIAL COMMERCIAL OTHER
WN
HAZARDOUS FIRE AREA
f YES ❑ It yes—I understand that a Class A
NAME 161 h l e.- sof assembly is required.
NO Initial - I.C.B.O.M
ADDRESS.9 0 Cd�d 1 EXISTING ROOF COVERING
PHONE
NUMBER OF EXISTING COVERINGS
CONTRA OR'
NAME III Nit-L,
-
S it-, I t "'---���
- Fie., TO BE REMOVED TO BE RETAINED -
i
ADDRESS 1 �S .Z / 1� (� /J IN
CITY 8 ZIP ( LSC l I /.JIC
EXISTING
tr
PHONE ` �3 I BUILT-UP ROOF -
LICENSE / "�
NUMBER S/OS�J ASPHALT SHINGLES ZI
LICENSED CO TRACTORS DECLARATION
1 hereby affirm that I em 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 CI 1sa � � Number S `f3 Data Zg --`1V Contractor OTHER(SPECIFY) ❑
OWNER-BUILDERDECIARATION PROPOSED
I hereby affirm that I em exempt from the Contractor's License Lew 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-U
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Lew(Chapter S(commencing with omSectionand 7000)of for the 3 of the
• Business and Professions Code)or that he Is exempt therefrom end the beefs he the applicant
to ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than flue hundred dollars($500).):
01,as owner of theproparty,or my employees with wages as their eels compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes.
alone Code:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑
improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for sale.If,however,the building or Improvement
is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
1,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sac.7044,Business and Professions Code:The Contractor's License Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who bunds or Improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
I]1 em exempt under Sec. ,B 8 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
prwill
have and maintain a Certificate of Consent to self-Insure for Workers Compensation, Bun
as provided for by Section 3700 of the Labor Code,for the performance of me work for which this PAID
® ildig
permit is Issued. "q .$elSrrllC
'Il have and will maintain Worker's Compensation Insurance,as required by Section 3700 of ��D ®9 /711rry 3 ('(-t y
the Labor Code,for the performance of the work for which this permit is issued.My Workers PR 2 O ANS
Compensatio, ,�
nIn,surance carrier and Policy number are: // / Total
CarrlerS 1{_�3� ('vhO PolicyNy. p IJIITI,AWXHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed If the permit Is for one hundred dollars($100)or teas.)
I certify that In the performance of the work for which this permit Is issued I shall not employ
any Perso in canny me r so as to become c.to the Workers'Compensation Laws°f call- All roofs be inspected prior to any roofing ma al being
r°`nia. S 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 Applicant understands and will comply subject to the Workers'Compensation provisions of the Labor Code,you moat forthwith comply PP ply with all non point
with such provisions or this permit shall be deemed revoked. urce 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 ll r0 coverings to be class"C"or better.
hereby authorize represenmtives of this city to enter upon the above-mentioned property for In-
sp(W) purposes.
(Wo)agree m save,Indemnify and keep harmless the City of Cupertino against Ileblllaee,
of the gran costs and expenses which may In any way accrue against said City In consequence
• of ins granting of this permu. IGNATURE O LICANT 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