R 5081 (2) PERMIT R_ 5081
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-.32 8 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
• 180 DAYS FROM UST CALLED INSPECTION.
BUILDING loADDDRRESS /�
(/ -7V/./ ��� RESIDENTIAL COMMERCIAL OTHER
OWNER'S / HAZARDOUS FIRE AREA
/p{,,/,�/'� YES 0 If yes—I understand that a Class A
NAME /O C.V/" roof assembly is required.
AN—
o Initial I.C.B.O.N
ADDRESS EXISTING ROOF COVERING
PHONE
Ov NUMBER OF EXISTING COVERINGS
CONTRACTOR'
NAME G. TO BE REMOVED TO BE RETAINED
ADDRESS „,Q// TYPE OF ROOF COVERING
CITY&ZIP !' 41
EXISTING
PHONE 49 BUILT-UP ROOF ❑
CENSE
NUMBER /D ASPHALT SHINGLE ❑
IF LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Divialon 3 of the Business and Professions Code,and my license is In full force and
enact. WOOD SHINGLES
License Claes Uc.Number
OTHER(SPECIFY) �j ❑
Date - Contractor
OWNER-BUILDER DECLARATION PROPOSED
hereby affirm that am exempt fromns the e:Contractor'scity License Law for the following reason,
cons.7031.5, ,Improve and Professions Code: Any city or county which requires e permit to
construct,alter,Improve,demolish,sind air any statement
h,prior to issuance,to
he provisions F-1 BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he is licensed pursuant to the Drovlelone
of theContractor's License Law 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 live hundred dollars($5001.):
❑I,es owner of the properly,or my employees with wages w their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes-
sions Code:The Contractor's License Law does not apply to an owner of property who bullas or WOOD SHINGLES
Improves thereon,and who does such work himself or through his awn 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(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 contractor(s)licensed pursuant to the Contractor's License Lew, PROVIDE MFGR.INSTALLATION SPECS.
C]I am exempt under Sec. ,B&P.C.or this reason
Owner
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION f PERMIT FEE
I hereby affirm under penalty of pedury one of the following declaration: p - d 1
E] `I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, BUIIdIn �
as provided for by Section 3700 of the Labor Code.or the performance of Me work for which this
permit Is Issued. Ui' Vv $elSlC
C]I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of rn
.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 AUTHORI ION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O ��/
(Thio section need not be completed If the permit Is for one hundred dollars(8100)or IBssJ „-'
I certify that In the performance of the work for which this permit i q shell not empl
any person In any manner eo a to become eubiect the Worker o ensmon Laws of Ca- All roofs shall beinspected prior to any roofing material being
forms installed. If a roof is installed without first obtaining an
Date 08 Applicant inspection,I agree to remove all new materials for inspection.
ou should become
subject Oto the Workers'Compensation prrovTICE TO APPLICANT: If,after isions of thethislcateLabor Code,you mA Exemption,ust forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shalQbe 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 roof oV rings tQQQ,,,����L class°C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
hereby
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• CityIn consequence SI AT RE QF,A PLICANT DATE of the granting of this permit.
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