R 5107 (2) PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER:.
INSPECTION DIVISION - PERMIT EXPIRATIO x
- 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
RESIDENTIAL� >COMMERCIAL " OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ es—I undOrstand that a Class A -
NAME roof assembly is required. '
NO I Initial I.C.B.6.N
ADDRESS EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTR OR'S a
TO BE REMOVE
- �TO BE RETAINED
NAME
ADDRESS F I 'o
CITY&ZIP SQ -
1 EXISTING.
BUILT-UP ROOF El
LICENSE
NUMBER YASPHALT SHINGLES
'LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES' ❑ V
7000)of Olvl 3 of ih sbvwa and Professions Cotle,and my license Is In lull farce and
anam � .c,l ►,.( WOOD SHINGLES ❑ , / ! j
License Close Lia Numb l l
Date Contractor
OTHER(SPECIFY) - ❑
ER-BUILDER CIARATIOI , PROPOSED 1
I hereby anlr that 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
constrapplicuCl,alter,Improve,demoto file signed airstatement
anystructure,Is licenor tose Issuance,to the
the BUILT,-UP ROOF % - q ,19pS
applicant for such permit to lila a signed atelement That he la licensed pursuant to the provisions 3 9 .
of the Contractors'License Law(Chapter B(common 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 L Imu.-
a civil penalty of not more than five hundred dollars 1$500).): Urs-n
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES - l
the work,and the structure Is not Intended or altered for sale(Sec.7044,Business and Profes.
slons Code:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑
Improves thereon,and who tloes such work himself or through his own employees.provided that '
such improvements are not Intended or offered for sale.If,howmaq the building or Improvement
1 Is sold within one year of completlonr the owner-builder will have the burden of proving that he did. OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
t.
[:J 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 a contractor(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS;
C]I em exempt under Sec. ,B&P.C.for this reason
Owner Aare
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
' - -
I heroby,efllrm under penalty of perjury one of the following declaration: "t _
❑1 have and will maintain a of the
of Consent to self-insure Por Worker's Compensation, �O I
eemitis Is for by Section 3]00 OIthe Labor Code,for the performance of the work Mrwhich this 11111^/� q �/`�') �'' SeBuilding �
permit ise and �J l�'v/�rn !r`'f�_'�J $QISmIC
❑ haveend will themaintain Workers Compensationkor Insurance,as required by Section3700 orkeof
the Labor Code,for the pe or rand of Ih rk for which this permit Is Issued.My Workers
C eonln° I rand Policy tabor are � �/ Total `77 CD
C �� PoI'yyyyNo J "�-C PERMIT AUTHORIZATION
"- CERTIFICATE OF EXEMPTION FROM WORKERS' - DATE
COMP .c
COMPENSATION N ❑
if.the
(This section need not be completed it the permit is for one hundred dollars(§100)or Iesa.)
I cerllly that In the performance of the work for which this rmit la Issued.I shall not employ
any aerao In any manner so as to become object to mew re'Comp nsalmn Laws of call- All roof^ II be inspected prior to any roofing material being
forinstallA. If a roof is installed without first obtaining an
t oat Appl lit inspection,I agree to remove all new materials for inspection.
NOTICE OAP LICANT: n,after making this Certificate of Exemption,you should become
subject to t war ratcpmpansanan provisions of the Labor Code,you must forthwith comply - Applicant understands and will Comply With all non 1point
with such provisions or this permit ahallibe deemed revoked. I .source regulations. -
I certify that l have read this application and state that the above Information Is correct.)agree '
to comply with all city and County ordinances and state laws relating to building construction,and All roof coveringts to be lass"C"or better.
hereby authorize representatives of this city to anter upon the above-mentioned property kr In. �T -y V
herebonpurpoae r - 1\/.111I\/tA\
(We)agree to save,indemnify and keep harmless the City of Cupertino against Ilablllties;
judgments,coats and expenses which may In any way accrue against said City In consequence
of the granting of this permit. SIGNATURE OF APPLICANT, DAT-
PRE-INSPECTION: PLYWOOD: _ IN-PROGRESS:
INSP. DATE INSP, - DATE INSP. DATE
TEAR OFF.INSPECTION: - BATTENS: i. FINAL: -
INSP. DATE INSP. DATE - INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE-PROVIDED FOR INSPECTION
-__ OFFICE COPY - .,,