R 5064 (2) PERMIT R_ 5 0 6 4
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
A 1e0 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
r/N RESIDENTIAL COMMERCIAL OTHER
OWNER'S f HAZARDOUSFIRE AREA
YES ❑ II yes—I understand that a Class A
NAME /NWmof assembly is required.
LZ O Inigal I.C.B.O.k
ADDR ss �i/�`4� 61+ EXISTING ROOF COVERING
PHONE
NUMBER OF EXISTING COVERINGS 1
CONTRACIi 9'
i/ TO BE REMOVED TO BE RETAINED
NAME Irk
ADDRESS �J / / �/JTYPE OF ROOF
CITY&ZIP
PHONE G�/ / �i'!/ BUILT-UP ROOF
LICENSE
NUMBER O ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DEFLARATION
I hereby affirm that em Business
under Professions
lone o1 Chapter y(commencing with Section WOOD SHAKES ❑
7000)of Division 3 0l the Bualnese entl Profaeslone Code,and my license is In lull ionto and
effect.
WOOD SHINGLES
License Class Lic.Number
Date Contractor OTHER(SPECIFY) ❑ T�/
OWNER-BUILDER DECLARATION Y 7 b
I hereby affirm that I am exempt from the Contractors License Law for the(allowing reason, PROPOSED -4U
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to V p
construct,Biter Improve,demolish.or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF �J ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions t n
of the Contrector's License Law(Chapter g(commencing with Section 7000)of Dlvlelon 3 of the 19v7
• Business and Professions Code)or that he Ia exempt therefrom and the basis for the alleged ASPHALT SHINGLESLL,-
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to t.
a civil penalty of not more than live hundred dollars($500).): rr /!V
❑1,as owner of me properly,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes.
Bions Coda:The Contrectofs License Law does not apply to an owner of property who build$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.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(See.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 contractoga)licensed pursuant to the Contractors License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑I em exempt untler Sec. ,B&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 declension:
❑I have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, /1,
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this //� D Building
permit is issued. a/6/
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of Seismic
the Labor Cotle,for the performance of the work for which this permit is Issued.My Worker's �' ( TOtflI
Compensation Insurance carrier and Policy number are:
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.O❑
(This section need not be completed If the permit Is for one hundred doll 100)or leas.)
I certify that In the performance of the work for whit Is permlt is 1 d, hall not em loy
any person any manner so as to become subject 1 e kers' ponsetion Laws of�an- All roots shall b petted prior to inyi0ofing material being
torula. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
become
sublactTt.theCE OWorkeres'Compensation provisions of the iiLabor Code,yocate lu mustforthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shell be deemed revoked. source regulations.
I certify that I have read this application and state that the above Information le correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,and All r0 f c grin o be class"C"or better.
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 any way accrue against said City In consequence
• of the granting of this permit. I ATUR PPLICANT DAT
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