R 5040 (2) PERMIT R_ 5040
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
180 DAYS FROM LASTCALLED INSPECTION.
BUILDING ADDRESS
00�, j f/� RESIENTIl COMMERCIAL OTHER
o NER's HAZARDOUS FIRE ARE
❑ A
/J/I YES If yes—I understand that a Class A
NAME—IVCSf—Y i � rooInmt assembly is required.
Will,r O I.C.B.O.#
ADDRESS / /J�/Xu(J EXISTING ROOF COVERING
PHONE Obi NUMBER OF EXISTING COVERINGS
CONTRACTOR'
NAME_- �j /
ADDRESS /��I TO BE REMOVED TO BE RETAINED
�G,% �YPE OF ROOF COVERING
CITU&ZIP V ( EXISTING�
PHONE BUILT-UP ROOF
LICENSE
NUMBER ASPHALT SHINGLESix
LICENSED CONTRAC S DECLARATION 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 Code,and my license is In lull force and
affect' WOOD SHINGLES
License Class Lic.Number
Date Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
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 requires a permit to
construct,alter,Improve,deal 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 Contractors License Law(Chapter g(commencing with Section 7000)of Division 3 of the
Buaineee and Professions Code)or that he la exempt therefrom and the basis for the allegedASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to L ,r
a civil penalty of not more than live hundred dollars(S500).): ^:� -
❑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 offered lot Bale(Sec.7044,Business and Profes- 14
slons Code:The Contractors License Law does not apply to an owner of property no builds or WOOD SHINGLES ry n
improves thereon,and who does such work himself or through his own employees,provided that /f} JnC
such Improvements are not Intended or offered for said if,however,the building or Improvement J(A
Is sold within one year of completion,the owner-builder will have the burden of proving that he didOTHER(SPECIFY) trLla-
not build or Improve for purpose of sale.). tiQ p
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct V
the project(Sec.7044,Business and Professions Code:The Contractor's 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(&)licensed pursuant to the Contractor's License Law. PROVIDE MI INSTALLATION SPECS,
❑1 am exempt under Sec. ,S s P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
. WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
El 1 have and will maintain a Certificate of Consent to self-insure for Workers Compensation, Building
as provided for by Section 5700 of Me Labor Code,for the performance of the work for which this IAC Seismic bo 0� / c
permit01 is Issued. /Y///,/, il $61Sn11C
❑ have and will the performance
Worker's Compensation the work
Insurance,0e requiredsu Section 3700 0l
the Labor Code,for the padormand of the work lar which rola permit Is Issued.My Worker's /
Compensation Insurance carrier end Policy number are: Total
Carrier Policy No. PERMITAUTHORIZATI DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.p
(This section need not be completed if the permit is for one hundred dollars fill 00)or lees.)
I certify that In the performance of the work for wh this permit ued, shell not employ
any person in any manner so as to become ruble t orke pensabon Laws of call- All roofs sl all be inspected prior to any roofing material being
forma. �� installed. If a roof is installed without first obtaining an
Date LilApplicant A,�� inspection,I agree to remove all new materials for inspection.
NOTICsubject toETO APPLICANT:thee Worrkers'Compef,after Irl neetion provisions of theflcgleof Laborr Code,Exemption,
must fo thwlithbecome
comply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked, source regulations.
I certify that I have read this application and stale that the above Information Is correct.I agree
to comply with all city and county ordinances and state Tawe relating to building construction,and All roof rOOf Ovv ngg class"C"Or better"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
sp(We) purposes. (�
(We)agree s save,expenses
and keep harmless the x,a of Cupertino against liabilities,
judgments,wets and expenses which may In any way accrue egalnet said Clty In consequence
of the granting of this permit SI TURE PLICANT DTE
PRE-INSPECTION: PLYWOOD: W-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