R 5570 (2) MIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 5570
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WRHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNE /l/'�/� HAZARDOUS FIRE AREA.
NAM �Tl�5Z� ( /7L/ Y YES ❑ II yes—I understand that a Class A
roof assembly is required.
NO Initial I.C.B.O.q
ADDR s[rJ� �•�Q/I Q T EXISTING ROOF COVERING
PHONE• — rJ NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
/��0� i 2� TO BE REMOVED TO BE RETAINED
NAME t
ADDRESS #D5'1� a 9�O�LfL EXISTING TYPE OF ROOF COVERING
CITY&ZIP
PHONE BUILT-UP ROOF ❑
NUMBER 7.2I o2 32 ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and
effect. WOOD SHINGLES ❑
License Class Llc.Number
Date Contractor
OTHER (SPECIFjM)'A I D ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors License Law for the lollcavi son. rQ(g�
(Sec.7031.5,Business and Professions Code: Any city or county which requires a p o R9
construct,alter,Improve,demolish,or repair any Structure,prior to Its issuance,also require BUILT-UP ROOF 1/ ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provision ]�'(�� {,u
of the Contractors License Lew(Chapter 8(commencing with Section]000)of Dm 10 ai he ASPHALT SHINGLESrtH (NQ
Business and Prolemions Code)or that he Is exempt therefrom and the basis for Y0 etl
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the ap a to
a civil penalty of not more than five hundred dollars($500).): /}t ❑
thatI,ea owner of the property,or my employees with wages as their aole compensation,wll WOOD SHAKES
rk,entl the structure le not Intended or offered far sale(Sec.7044,Staff ae anal Proles-
alone Coale:The Contractors License Law does not apply to an owner of property who bullda 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.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) El
build or Improve for purpose of sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Prolesslons Code:The Contractors License Lew 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 Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
owner Date AP I TION DATE VALUATION PERMIT FEE
V 1 SATION DECLARATION
hereby ellirm untlar penalty of perjury one of the/allowing declaration:
❑I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, Building
as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which t s 4'—
permit Is Issued. ,/fy..' .r
❑ have and will maintain Worker's Compensation Insurance,as required by Section 37000 VVD SeIS
the Labor Coda,for the performance of the work for which this permit Is Issued.My Worker's `(/� �r
Compensation Insurance carrier and Policy number are: F[r -Total
Carrier PoIlcyNo. P MIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N C
(This section need not be completed It the permit Is for one hundred dollars fill 00)
or lase.)
I certify that in the performance of the work for which this permit Is Issued,I shall not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Can- All roofs shall be inspected prior to any roofing material being
fornia. 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: If,after making this Certificate of Exemption,you should become Applicant understands an I with all non point
Subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pp Y p
with such provisions or this permit shall be 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 an city and county ordinances and state laws relating to building construction,and All roof Coverings t0 eClasS" atter.
hereby authorize rapt esenmtivea of this city to enter upon the above-mentioned property for In.
ep on purposes.
two,
Z
(Wen agree to save,Indemnity and keep harmless the Glry of Cupertino against liabilities,
of Ipmarts,costa and permit. s which may In any way accrue against eeltl City In consequence
onhe granting of this permit. SIG RE OF APPLICANT ATE
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
-r INSP. DATE INSP. DATE INSP. DATE
TEAR OF INS ECTION: �—/ BATTENS: FINAL:
INSP. DATES INSP. "DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
� .
OFFICE COPV.