R 5559 (2) c
MIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 5559
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 ADDRESS
93 _ RESIDENTIAL COMMERCIAL OTHER
OWNER's HAZARDOUS FIRE AREA
NAME OY� ' J VES ❑ If yes s I mbly is reqand that a Class A
Roof assembly is required.
C NO ❑ Initial I.C.B.O.#
ADDRESS / EXISTING ROOF COVERING
PHONE -7A-5 — 6 Z NUMBER OF EXISTING COVERINGS
CONTRACT
TO BE REMOVED - TO BE RETAINED
NAME
ADDREss �J$-,Q� x"17 TYPE OF ROOF COVERING
CITU✓;ZIP.T�6.G � a�b EXISTING
PHONE !�D—C;O 3 —/1 --As BUILT-UP ROOF
LICENSE
NUMBER ❑ASPHALT SHINGLES r
LICENSED CONTRACTORS DECLARATION
I hereby allirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effectLicense
WOOD SHINGLES ❑ �l
License Claes Llc.Number Q
Date Zf I Contra-far OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARAT N PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason. 0.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to p i
construct,altar,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF Ir
applicant for 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 SHINGLEAPR 3 AND
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 dollars($500).): WOOD SHAKES
❑I,as owner of the property,or my employees with wages as their sole compensation,wi 11 do CITY
r�
the work,and me structure is not Intended or offered for sale(Sec.7044,Business and Profes. CII 1 UI- vorc IIVV
sions Code:The Contractor's License Law dose 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.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the Protect(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(hereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
[II am exempt under Sec. ,B&P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby aeirm under penalty of perjury tuna of the following declaration: /O
❑I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, b 7
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this � �/�� L`/ Building
paki Is issued. V f0
�QI have and will maintain Worker's Compensation Insurance,as required by Section 3700 of $eISR11C'
ih Lgbar Code,for the performance of the work for which this permit Is issued.My Workers
cam
pensaaon Ina��--n////�@@--carrier and Policy number are: `n Total
carrier �• fir r.A - P011cyNo,:S— ` f •/� PERMITA THORIZATION 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.)
1 certify that In the performance of the work for which this permit is issued,I shall not employ 0J
any person in any manner so as to became subject to the Workers'Compensation Laws of Cell. All r s she a inspected prior to any roofing material bei
forma. - 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
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shallibe 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 CQVerin be Class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in. •X/`,J[/)/ r /
apache)purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against il--------- s i
of the gran coats and expenses whish may In any way accrue against eeltl City In consequence
ohne granting of this permit. SIGNATURE 9FAPPLICANI 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY