R 5079 (2) PERMIT R_ 5 0 7 9
-APPLICATION FOR CITY OFCUPERTINO 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 0 soaflv -
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
r YES I7 If yes-I understand that a Class A
NAME roof assembly is required;
— WInitial I.C.B.O.#
ADDRESS50� `! EXISTING ROOF COVERING
WPHONE
. NUMBER OF EXISTING COVERINGS
CONTRACT 'S
NAME AfAx- ��;� ��(:• TO BE REMOVED TO BE RETAINED
ADDRESS 1TYPE OF ROOF COVERING
CITY a ZIP
EXISTING
PHONE BUILT-UP ROOF ❑
CENSE
NUMBER �D - ASPHALTSHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Cotle,and my license Is In lull force and -
effect.
WOOD SHINGLES
License Class Lic.Number ,
Date Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from the Contractors License Law(or 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-UP ROOF
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
01 the Contractors License Law(Chapler B(commencing with Section 7000)of Division 3 of the r
• 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($500).): -
C]1.as owner of the property,or my employees with wages as their able compensation,will do WOOD SHAKES
the work,and the structure Is not intended or offered for sale(Sec.7044,Business er)d Profile- \7
alone Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLE$�ej,�� v,
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.). V'
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 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 contrector(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
E]I em exempt under Sec. ,B 8 P.C.for this reason
Owner
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE VALUATIOX PERMIT FEE
I hereby affirm under penalty of perjury one of the Milowfng declaration: 'A1
❑1have and willmaintain0 of the
Labor
Consent to Performa for Worker's Compensation,his �. (A I� 7 Building
as provltlstl/or by ill main 3700 of the Leber Code,for the performance W the work for which this /ttVp/
permit is Issued. S81StitIC
❑1 have and will maintain Workers Compensation Insurance.as required by Section 3700 of
,the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's
Compensation Insurance carrier and Policy number are: V Total
Carrier Policy No, ERMITAUTHORIZATIONATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C. - �� / /IZ tel/
(This section need not be ao co oletl If the permit le for one hundred dollars($100)n or lase.) 7"�LG4-GG !'( f� 7 C�
cenityIhet in the performance of me work for which rola permit la Is shell not employ
any perao n any manner as to become subI ct he ream'c l atlon Laws of Call- All roofs shall be inspected prior to any roofing material being
� installed. If a roof is installed without first obtaining an
Date f�IJ !( Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,a8er making This Cer Ilicale xemptlon,you ehoultl become Applicant understands and WIII comply
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP ply with all non point
with such provisions or this permit shalflbe 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 city and county ordinances and state laws relating to building construction,and All roofO ingS � 7e Class"C"or better. rl
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spectlon purposes. �/•/( (y/_y(/J6
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may In any way accrue against mid City In consequence
• of the granting of this permit. S GNA URE OKAPPLICANT 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
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