R 5053 (2) PERMIT R_ 5053
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 160 DAYS OF PERMIT ISSUANCE OR
• 160 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS I -/,
1a161
(/ RESIDENTIAL COMMERCIAL_OTHER
OWNS 'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME root assembly is required.
�j NO - Initial I.C.B.O.#
ADDRESS r� ,R EXISTING ROOF COVERING
PHONE 1111410"v / NUMBER OF EXISTING COVERINGS
CONTRACTO S /
r TO BE REMOVED TO BE RETAINED
NAME
ADDRESS - V
CITY&ZIP (TYPE OF R F COVERING
PHONE
BUILT-UP ROOF ❑
CENSE
NUMBER ASPHALT SHINGLES
-LICENSED CONTRAC RS DECCARAIMON
I hereby affirm that I am licensed under provisions of Chapter S(commencing with Section WOOD SHAKES ❑
700 0)of Division 3 of the Business and Professions Code,and my license Is in full force and
affect.
WOOD SHINGLES
License Claes Lic.Number
Date CntfaCtof OTHER(SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Lew for the hllowing reason. '- /, s
(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 provislons
of the Contractor's License Law(Chapter 0(commencing wlth Section 7000)of Division 3 of the A(//�
• Buelnesa and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES' 9198
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to JJ
a civil penalty of not more than five hundred dollars($500).): t'fly,ter,
El 1.as owner of the property,or my employees with wages as their sale compensation,will do WOOD SHAKES GU,,C, ❑
the work,and the structure Is not Intended or offered for sale(Sac.7044,Business and Prohs. iy/y(,V
.Ions Code:The Contractor's License Law does not apply to an owner f property who builds or WOOD SHINGLES
Improve$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
1$sold within one year of completion,the owner-bullder.111 have the burden of proving that he did OTHER(SPECIFY) ❑
not bul Id or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improve$thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
I]I em exempt under 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 declaration:
❑1 have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, Blllldin
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this A /n{ g
permit is lee / (�� l r Seismic
[II have and antl will maintain Worker's Compensation Insurance,as required by Section 3700 of /U1 l
-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: Total
Carrier Policy No. PERMIT AUTHORIZATIONDTE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.I]
(This section need not be completed If the permit Is for one hundred dollar.($/00)or less.)
I certify that In the performance of the Work for.hK his permit I esBetl, shall not employ
any parson In any manUr so as to become eubjec 6 in orker ompeneatlon Laws of Calf All roots shat a inspect prior to an roofin ate lal eing
fornla' , installed. If a roof is installed without firs obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO subject to the Wor ere'CompensatICANT. N, e n provir Maki sions of then AN flLe ar Coda you must forthwieh comply Applicant understands and will comply with all non point
with such provisions or this permit shalf;be deemed revoked. Source re ulations.
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 to CO ring1t b IaSs"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes.
(We)agree to.eve,expenses
and keep harmless the Clry ai Cupertino against liabilities,
O
judgments,coats and expenses which may In any way accrue against saitl City in consequence
of the granting of permit. A ATUREPIFAPPLiCANT 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