R 5768 (2) PERMIT R_ 5768
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
• BUILDING ADDRESS n
RESIDENTIAL___? COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑' If yes—I understand that a Class A
NAME - roof assembly is required.
NO ❑ Initial I.C.B.O.N
ADDRESS EXISTING ROOF COVERING
PHONE 2S ZOp-4/ NUMBER OF EXISTING COVERINGS rZ_
CONTRACT 'S /
TO BE REMOVED �� TO BE RETAINED
NAME 7:9 AP
ADDRESS / 90 " TYPE OF ROOF COVERING
CITY ZI ✓ c/d-2,�
EXISTING
PHONE—,D-Cdl ' �0 7S// U BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES '
LICENSED CONTRACTORS DECLARATION /❑ /O�
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES L
7000)of Division 3 of the Business and Professions Cotle,and my license Is In full force and j
effect / WOOD SHINGLES ❑
License Clp !� Lice Number s+' `r-+
Dote 'T/ �0 Contractor ' OTHER(SPECIFY) ❑ —/ �'—
OWNER-BUILDERDECLAfl ON PROPOSED
I hereby affirm that I em exempt from the Contractors License Lew for the following reason.
(Sec.7031A Business and Professions Code: Any city or county which requires a permit to
construct,for alter.Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF ❑
appllcanl such permit to file a signed statement that he is licensed pursuant to the provisions
of the Contractor'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 five hundred dollare($500).):
E]1,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 for sale(Sec.7044,Business and Profes.
alone Code:The Contractor's License Law does not apply to an owner of property who builds or
Improves thereon,and who does such work himself or through his own employees,provided that ❑
such Improvements are not Intended or offered for sale.I(however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did O?VIDE
R ( A Y) ❑
not build or Improve for purpose of sale.).
E]1,as owner of the property,am exclusively contracting with licensed contractors to construct ' 11
the project(Sec.7044,Business and Professions Code:The Contractor's License Lew dose not PIC5E.P.E2D ff3 U s�
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 Law,
P MFGR.INSTAL SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for this reason
Owner DateAPPLI PERMIT FEE
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declaration; ./� y3
❑ haveand willmaintaina of the
Labor
ate bof Consent to performance
Workof
work
Compeor nsation.this /� / O✓ Building J O
as provided have
lardy ill main ain a of me Leeor Code,for to
perfnauro for
the work mpensh ion. .[7�./
p r II is Issued. $eISn11C
have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
IhEEEE Labor Cotle,for the performance of the work for which this permit Is Issued.My Worker's /
Compeneatlon�Ine�uTm�6 carrler and Policy number are: Total
.Carrier �` �& Policy klo.sil-/q•'f /a7Q PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.p G
(This section need not be completed If the permit Is for one hundred dollars($100)or lase.)
I certify that In the performance of the work for which this permit Is Issued,I shall not employ
any person Ina manner so as to become subject to the workers'Compensation Laws of can- All roofs shall be inspected prior to any rooting material being
forma. ii� /Q installed. If a roof is installed without first obtaining an
Oat.
ASIF091
Applicant �� inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: ll,after making this Certificate Exemption,you should become Applicant understands and will comply with all non point
subject to the Workars'Compensation provisions of the Labor Coda,you must forthwith comply pP P Y P
with such provisions or this permit snail be doomed 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 root COV rin aclass"C'or better.
hereby authorize representatives of This city to enter upon the aeove•mentlonad property for in.
//�Q�sr x'(J
spection apurposes. //Vl
(WB).gree to esus,Indemnity and keep harmless the City of Cupertino against liabilities,
lutl mems,cosro entl expanses which may In any way accrue against said City In consequence
ofggronung.1thispermit. SIGNATURE OF PPLICANT ATE
• 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