R 5083 (2) PERMIT R_ 5083
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
• 180 DAYS FROM LAST CALLED INSPECTION.
/`NhG ADDRESS
BUILDING ? ,GO
[/(/e,-V �/iT/ I / RESIDENTIAL COMMERCIAL OTHER
OWNER'S / HAZARDOUS FIRE AREA
NAMEft1l MOP/ r VES Elaoyof assembly is rrequired, Class A
NO Initial I.C.B.O.#
ADDRESS / EXISTING ROOF COVERING
PHONE
�aZ/ NUMBER OF EXISTING COVERINGS
CONTRACTOR'S xJ
TO BE REMOVED TO BE RETAINED
NAME v
ADDRESSit? //'�'�/�/� BL E OF F COVERIN
CITY aZIP fJ /,G/�/�/` (7�' ] EXISTING
PHONE v r BUILT-UP R ❑
LICENSE ,7
NUMBER v ' ASPHALT SHINGLES ❑ .
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES J ❑
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
allect. WOOD SHINGLES-2 �
License Class Lid.Number /
Date Contractor OTHER(SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED w[
I hereby affirm that I am exempt from the Contractors License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which r6qulres 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 Contractor's License Lew(Chapter 9(commencing 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($500)J:
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or a#ered for seta(Sec.7044,Business and Profes.
sions Code:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑
Improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for sale.It,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such project.
with a contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
E]I am exempt under Sec. ,B a P.C.for this reason
Owner oats
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: o ,
❑I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation,
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this (/Jj� Building
permit Is Issued. ' / n$el iR � 3 O
❑I have and will maintain Workers Compensation Insurance,as required by Section 3700 of A A AUG 2 C
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's (y� '1/1 7-"351, bo
,the
insurance carrier and Policy number are: 7V/ V 1 Total
Carrier Policy No. ERMITAUTHO I TION ` `.•"'•DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 100)o /�
(This section need not be completed If the permit is for one hundred dollars($100)or lase.) _ L/(/
1 certify that In the performance of the work for w h this per Issued,I shall not employ
any person In any manner so as to become subjec a war ue ompensatlon Laws of Cell- All roof^shall be-inspected prior to any rooting material being
forma. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It,after making this Carfificaft of Exemtion,you should become Applicant understands and will 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 shalcbe deemed revoked. Source regulations.
I certify that I have read this application and state that the above Information le correct.I sores
to comply with all city and county ordinances and state laws relating to building construction,and All r0 c eringiii be class"Ci"Or beitB
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 Ilebilinea,
judgments,costs and expenses which may in any way accrue against said City in consequence -All All
. of the granting of this permit. SIG A URE C
,VAPrLICANT 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