R 5905 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 5 9 0 5
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
!/ (/ OG QO Ape RESIDENTIAL COMMERCIAL OTHER
OWNER'S _ �/ �1,� (� HAZARDOUS FIRE AREA
/}RAryx-J VES ❑ If yes—IunderstandthataClassA
NAME ryf� roof assembly is required.
,^ NO ❑ Initial I,C.B.O.N
ADDRESS /4 4?49 , ` �,�� f vl:r U.15IING ROOF COVERING
Q
PHONE v —7 c::!) 7— NUMBER OF EXISTING COVERINGS
CON
TRACTO8 - -
TO BE REMOVED TO BE RETAINED
M
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP
EXISTING
PHONE BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES
' LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect.
WOOD SHINGLES ❑
License Cleae LIC.Number
Date Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
hereby affirm that I am exempt from the Contractors License Law for the following reason.
IS
7031.5,Business and Professions Coda: Any city or county which requires a permit to
construct,alter,Improve,demolish.or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions rs
of the Contractors License Law(Chapter 8(commencin 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 dollars($500).):
❑l,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 Proles.
slons Code:The Contractors 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 own employees,providod that
,- such improvement&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 project(Sec.7044,Business and Professions Cotle: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 Ili pp
with a contractogs)licensed pursuant to the Contractors License law.
❑I am exempt under Sec. ,B&P.C.for this reason PROVIDE MFGR.INSTALCATI SPECS.
.1110
Own s Detee APPLICATION DATE AL PERMIT FEE
OR R S COM NSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to sell-Insure for Workers Compensation, Uh LUrChfilly j 1 BUI
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit le Issued. 110(44—
BBIS
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
_the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's
Compensation Insurance carrier and Policy number are: Total
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.p
(This section need not be completed If the permit Is for one hundred dollars(15 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 subjoin to the Worker&'Compensation Laws of Cell. All roofs shdillbe inspected prior td,any r ofin vial being
torula. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
ecome
subject to
NOTICE
TO APPLICANT:the Workers'Compeneetlorn prolvisions of theficate of Laborr Code,yolu mustufothwou 111hbcomply Applicant understands and will comply with all non point
with such provisions or this permit shalQbe 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 coverings to be class"C"or better.
hereby Sulfates representatives of this city to enter upon the above-mentioned property for in.
spection purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
'judgments,cast&and expense&which may In any way accrue against said City In consequence
of the granting of this permit. URE101"APPLICANT DATE
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