R-5409 (2) APPLICATION FOR CITY OF CUPERTINO
NUMBER PERMIT
R— 5409
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 ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNERS HAZARDOUS FIRE AREA
, r VES If yes—I understarM that a Class A
NAME (1 (l roof assembly is raquinad.
/`, • - - NO Initial I.C.B.O.N
ADDRESS�/�. ./. es *L /)r� ��� EXISTING ROOF COVERING
Qr�
PHONE NU BER OF EXISTING COVERINGS
CONTRACTOR'S
TO BE REMOVED_42� TO BE RETAIrIr
NAME
ADDRESS TYPE OF ROOF COVERING
CITU 8 ZIP
EXISTING
PHONE 17J BUILT-UP ROOFLICENSE
❑
NUMBER ASPHALT SHINGLES ❑/
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES I� •O
7000)of Division 3 of the Business and Professions Code,and my license is in full force and
effect.
/, WOOD SHINGLES El Class` Us Number
Date Contractor OTHER(SPECIFY) 1:1
OWNER-BUILD&960WATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the fallowing 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 ❑
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions
of to Contractor's License law(Chapter 9(commencing with Section 7000)of Division 3 of the
. Business and Professions Coda)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
a civil penalty of not more than five hundred dollars($500)J:
❑ WOOD SHAKES I,as owner of the property,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 Proos-
sions Cotle: 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-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
net build or Improve for purpose of sale.).
❑I,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 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)licensed pursuant to the Contractor's License Law. .PROVIDE MFGR.INSTALLATION SPECS.
❑1 em exempt under Sec. ,B 8 P.C.far this reason
Owner Dale APPLICA A VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION Q
I hereby affirm under penalty of perjury one of to following declaration: },
have end will maintain a Certificate of Consent to self-insure for Worker's Compensation, SEP 11 [ Dyr� Building
as provided for by Section 3700 of the Leber Code,for the performance of the work for which this � C^
permit01 Is Issued. C17v U, 'Y4 .S,eis
❑I have and will maintain Worker's Compensation Insurance,as requiredsu Section 3700's 1 1 _
the Labor Code,for the performance of the work for which this permit is Issued.My Worker's ��Ntp))N Tota
Com anaetlonIn uranc carrier a Polic umber A. /Q _`M7%
Carrierr Policy No './!L 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 so as to become subject to the workers'Compensation Laws of Cell- All roofs s II be nsp cted prior to any roofing material being
fame. installed. If a roof is installed without first obtaining an
Dale Applicant inspection,I agree to remove all new materials for inspection.
subecct toEe Worrkers'Compefnsalo provisions ofetheiflLaborr Codemyolu must forthwitlhbcomply Applicant unders nds,an will comply with all non point
with such provisions or this permit shaill deemed revoked. Source regu
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 con struction,and A f00 O Or ett
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may in anyway accrue against said City in consequence E Q APPLICANT AT
• 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 I DATE
NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY