R-5687 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBERR_ 5687
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
• BUILDING ADDRE/SSS���)
2 L V A_ VrK�� RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
�( ,'LN11 YES E] If yeaI understand that. Class A
NAME
roof ass sembly is required.
2.`�
Initial- C.B.O.N
ADDRESS � !'�/�,� � � EXISTING ROOF COVERING
�'\
PHONE 7(l relief, ! 01"t NUMBER OF EXISTING COVERINGS
CONTRACTOR'S 6IL `
'V,.JyV[/V. TO BE REMOVED TO BE RETAINED
.!NAME
ADOHtSS E OF ROOF COVERING
CITY a ZIP EXISTING
PHONE BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES rd
of Division 3 of the Business and Professions Code,and my license is in lull torte and
effect.
WOOD SHINGLES ❑
License Class Lic.Number
Date Contractor OTHER (SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED O
I hereby affirm that I am exempt from the Contractor's License Lew for the following reason.
(Sac.7031.5,Business and Professions Code: Any city or county which requires a permit to ❑ w�
construct,alter,Improve,demolish,or repair any structure,prior to its issuance,also requires the BUILT-UP ROOF of
the Co for such permit to file a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Lew(Chapter B(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 leve hundred dollars($500).): WOOD SHAKES
[:]I,as owner of the property,or my employees with wages as their sole compensation,will do ❑
the work,and the structure is not intended or offered for sale(Sac.7044,Business and Proles-
slons Code:The Contractor's 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 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.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to construct
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 actors)licensed pursuant to the Contractor's License Lew.
1 a under Sec. ,B s P.C.for this reason PROVIDE MFGR.INSTALLATION SPECS.
�. 'r ^ Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
E] PP A I have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
r
permit lsIssued. � mic
JUSets
❑1 have and w1II maintain Worker's Compensation Insurance,as required by Section 3700 of du
the Labor Code,for the performance of the work for which this permit is issued.My Worker's L z 8
Compensation Insurance carrier and Policy number are: Total
Carrier Policy No. TIEFMIt-rifilt ORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed If the permit is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this permit is issued shall not employ
any person in any manner so as to become subject to the Workers'Compensation Laws of call- All roofs shall be inspected prior to any roofing material being
fornea. installed. If a root is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,eller making this Certificate of Exemption,you should become Applicant understands and will I with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP comply Y P
with such provisions or this permit shalllbe 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 rely and se county ordinances and state laws relating 1r anti ng construction,and All OOf C Verl gs ip O b2 Class r Bette(.
hereby authorize representatives of this city 10 enter upon the above-mentioned property for in. 1r`/<d1)'\/Y,1'n�--(^JLI
ri
spection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs and expanses which may in any way accrue against said City in consequence ,
• of the grantingofthispermit. IGNATURE OF APPLICANT DATE
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP.-DATE- INSP.-DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE INSP. DATE INSr,. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
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