R 5065 (2) APPLICATION FOR CITY OF CUPERTINO
NUMBIER R- 50 6 5
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES W WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION,
. BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
� VES ❑ If yes—ssemhy I understand thatClass A
NAME _ /1/ / CC//1//�"�/ Is required..
�"Tj,�",, root e
❑ Initial I.C.B.O.K
ADDRESS-&rG _ n EXISTING ROOF COVERING
PHONE
G i G NUMBER OF EXISTING COVERINGS
CONTRACT
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS / L TYPE OF ROOF COVERING
CITY&ZIP (% L- ! ,"
/ EXISTING
PHONE r BUILT-UP ROOF AUG 1 g996
LICENSE >,r•I
NUMBER ASPHALT SHINGLES ) Q" Lt, ❑rr kU
LICENSED CONTRACTORS DCLA ATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Cade,and my license is In lull force and
effect.
WOOD SHINGL
License Class Lia Number
Date Contractor
OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for 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 lila a signed r 9(commencing
that g with
pursuant to the provisionsothe
of the Contractors License Lew(Chapter h(commencing with Section 7000)of for the 3 0l the
•
exemption.
and Professions Code)or that he Is exempt therefrom and the basis for ins alleged ASPHALT SHINGLES
a civil pen.Anyfviolationtmore
of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of not mora then five hundred dollars(h wag):
❑Las ownerofsth crure I not I tendedmy employeeswithwages(as Sec.their Bole compensation,sand
Pr if s. WOOD SHAKES
the work,and the structure la not Intended or offered Tory to(Sec.7044,Business antl builds
or
Iter Code: 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 forW Bale, ill however,the building pr vi Improvement
is sold not
or hin
prove for urposetof sale.).owner-Wilder will have the burden of proving that he tlo OTHER(SPECIFY) ❑
not bulltl or Improve for purpose of sale.).
❑1,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(SBC,7044,Business and Professions Code:The Contractor$License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds of Improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
(JI am exempt under Sec. ,B&P.C.for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑ have and willmaintaina of the Labor
Consent todelbineurefar Worker's Compensation,
this a^/ q1b
Buildinee Ej I h v tar dy ill main ain a of the Labor Cons nt the pedrsure f r W re iworksC for which ton, 1//Vf/,/I/P(•/ g
permit is Issued. Seismic
[:11 have and will maintain Worker's Compensation Insurance,as required by Sectlan 3700 of ,�'y,
_the Labor Coca,for the performance of the work for which this permit Is Issued,My Workers Vp
Compensation Insurance carrier and Policy number are: V \ Total
Carrier Policy No. PERMIT AUT RIZATION
FROM
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 whip this permit Is�aegsl I shall not employ
any person In any manner so as to become subject 6th Workers' t mS pafisation Laws of Call. All roofs shall be intipected prior to any roofing material being
fornia'(�a/�' & installed. If a roof is installed without first obtaining an
Date ILAPPLS Appnaam - inspection,I agree to remove all new materials for inspection.
subjectlo the ooW„orkers'Compense on proIf,after lvisionts of the lLabor Code,you ,you should become Applicant understands and will comply with all non point
you must forthwith comply p y
with such provisions or this permit she be deemed revoked. ]source re ulations.
I certify that I have read this application and state that the above information Is correct.I agreeto comply with ell city antl county ordinances and state laws relating to building construction,end ll too O ring O be class"Ci"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
ap(We) purposes.
(We)agree to save,pe indemnity w antl keep harmless the City ai Cupertino against liabilities,
judgments,costa and expenses which may In any way accrue against said City in consequence
of the granting of rale permit. GNA URE 9FAPPLICANT 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