R 5176 (2) PERMIT R_ 517 6
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 LAST CALLED INSPECTION.
BUILDING ADDRESS A 7��1
D ¢��oN� cf� RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
nApn � /- YES ❑ It yes—I understand that a Class A
NAME "`�W� d,7 T NO roof assembly is required
iel I.C.B.O.q
ADDRESS l� fi4ek" i tt ctZ • EXISTING ROOF COVERING
PHONE
253- 3 6M NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S
NAME LL'Ll�h� TO BE REMOVED TO BE RETAINED—
ADDRESS TYPE OF ROOF COVERING
cITYBzIP 0331q 4-45 0,7P*5
EXISTING
/(f
PHONE�r oe-� 86 4" 9�rV Z•- BUILT-UP ROOFLICENSE
❑
NUMBER 7 va 179 ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license is In lull force and
effect.
WOOD SHINGLES
Cleanse CI-- C-- 3'9 Lia Number 7 40
O ❑
Data Contractor OTHER(SPECIFY)
OW NER-BUILDER DECLARATION PROPOSED
hereby affirm that I em exempt from the Contractor's License Law for the following reason.
(Sac.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct alter,Improve,demollsh,or repair any structure,prior to Its Issuance,alsorequlreslhe BUILT-UP ROOF ❑
appllcAnt for such permit to file a signed statement that he is licensed pursuant to the provisions
• of the Contractors License Lew(Chapter g(commencin with Section 7000)of Division 3 of the
Business and Professions Code)or that he Is exempt Iherefrom 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 of not more than five hundred dollars($500).): 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 allered for sale(Sec.7044,Business and Profes-
sions Code;The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES El
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 build ng 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(Sec,7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.0,REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
win a contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
01 am exempt under Sec. ,B 8 P.C.for this reason
OwnerDate
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: (7
❑1 have and will maintain a Certificate of Consent to eelt•Insure for Worker's Compensation, 3Fp BUl ding�
as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which this /� 2ry
permit Is Issued. r J / ,r5 $eISn11C
❑ have and will melnleln Worker's Compensation Insurance,as required by Section 3700 of r 9
the Labor Code,for the performance of the work for which this permit is Issued.My Worker's J
Compensation Insurance carrier and Policy number are: , L, .4 O Total
Carrier Policy No. PERMIT'AUTHORIZATION DATE
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 lose.)
I certify that In the performance of the work for which this permit Is Issued,I shall not amylay
any person In y man or so as to become subject to the Workers'Compensation Laws of Call- All roofs shall be inspected prior to any roofing material beleg
ornia. i c installed. If a roof is installed without first obtaining an
Date _ �� Applicant C 2 - inspection,I agree to remove all new materials for inspection.
NOTICtTOA PLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and will I with all non point
subject to the Workers'Compensation provisions of the Labor Coda,you must forthwith comply pp comply 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 ma above Information Is correct.I agree
to comply with all city and county ordinances and stale laws relating to building construction,and All r. of coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above mentioned property for in.
speedo)purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against Ilebllllloe, (�
• judpmenle coele entl expenses which may In any way accrue against said City In consequence
oftRegrentngofmlepermu. SIGNATURE 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY _ 1