R 5077 (2) PERMIT R_ 5077
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
1B DAYS FROM LAST CALLED INSPECTION.
• BUILDING ADDRESSle�
/_`J //�� Ive
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
VES ❑ If yes—I understand that a Class A
NAME Srroof assembly is required. LC.B.O.fr
ADDRESS—, EXISTING ROOF COVERING
PHONE �Z NUMBER OF EXISTING COVERINGS
CONTRACTO '
NAME Ole TO BE REMOVED_Y_TO BE RETAINED
ADDRESS X-9
CITY 8 ZIP ' ��/
Emma
PHONE 0 ' v✓ BUILT-UP RO ❑
NUMBER LICENSE ASPHALT SHINGLEEl
LICENSED CONTRACTORS DECLARATION
hereby,affirm that em Business
licensed under Professions
loss of Chapter y(commencing with Section WOOD SHAKE ❑
7000)of Divielon 3 0l the Bualnesa entl Proleeeions Code,and my license Is In lull lone and
effect. WOOD SHINGLES j ❑
License Class Lie.Number
Date Contractor OTHER(SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors License Law for the following reason.
IS
7031.5,Business and Profeeelons 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 the• Co5haetor°License Law(Chapler g(commenelog 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 ❑
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($500)):
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes-
sions Code:The Contractor'°License Law does not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,provided that ❑
such Improvements are not Intended or offered for sale.If,however,the building or Improvement
Is sold within one year of completion,the owner-builder.111 have the burden of proving that he did OTHER(SPECIFY) El
build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec,7044,Business and Professions Code:The Contractor's License Lew does not PROVIDE I.C.B.O. REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
C]I am exempt under Sec. ,S B P.C.for this reason
Owner De1B APPLICATION DATE VALUATIO PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: ��� -
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, _�/s_ Sulldingl 7 7 as provided for by Section 3700 of the Labor Code,for the performance of the work for which this /v,
permit Is Issued, f1yV( +$BISrn IC •l
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of 1 IiQ 2 2 19 O
.,the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's ! / 3
Compensation Insurance carrier and Policy number are: _ G/ TOtaI
Carrier Polley No. P RMI ZATION.. `rr. .. YATCERTIFICATE OF EXEMPTION FROM WORKERS' ItCOMPENSATION INSURANCE N.C{](TMs section need not be completed if the permit Is for one huntlred dollars($100)or less.) uKi /y/
I certify that In the performance of the work for which this permit Is sued,I shall not em toy SSS�00
any peg any manner to become subject t Worker o pensation Laws of all- - I roofr' a e inspected prior to a y roofing material being
fornle.
�/ installed. If a roof is installed without first obtaining an
Dote Appficant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certillcet of fumption.you should become
subject to the Worker°'Compensation provisions of the Labor Code,you must forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shelllbe 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 cityand county ordinances and stele laws relating to built construction.and All an be class"C"or better.
hereby
herebauthorize representatives of this city to enter upon the above-mentioned property Mr in.
y
purposes. b(/J6
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
judgments,
grating of this expenses
es which may In any way accrue against said City in consequence
ftxSIUNATUFIE 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