R 5487 (2) [NUMBIP R 5487
INSPECTION FOR CITY OFCUPERTINO
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777.3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
ISO DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
790 MCW&/, At4 GPixX "" RESIDENTIAL COMMERCIAL OTHER
OWNER'S / HAZARDOUS FIRE AREA
YES ❑ If yes-1 understand that a Class A
NAME_ roof assembly is required.
N Initial I.C.B.O.#
ADDRESS �(3,
Sri-
PHONE
ROOF COVERING
PHONE 0 ry-� a 7 NUM ER OF EXISTING COVERINGS 3
CONTRACTOR'S t
TO BE REMOVED 3 TO BE RETAINED
NAME r
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP L c
!- , EXISTING
PHONE BUILT-UP ROOF P_
LICENSE tid 7 2 ASPHALT SHINGLES
NUMBER 7 ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em 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
affect.
WOOD SHINGLES ❑
License Class C Llc,Number_ Z Y
Date T -
//3-9Contractor +4 .r� �( (e OTHER(SPECIFY) ❑
— — V_T /
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason. x=�
(Sec.7031.5,Business and Professions Code: 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 4.+�
applicant for such permit to Ills a signed statement that he is licensed pursuant to the provisions
of the Contractors 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
e civil penalty of not more than five hundred dollars($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 Profea-
slonsCode: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 own employees,provided that ❑
such improvements are not Intended or offered for sale.II,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) El
build or Improve for purpose of sale.).
❑I,as owner of the property,am exctusively contracting with licensed contractors to construct
the project(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 thereon,and who contrails for such projects
with a contractor(s)licensed pursuant to the Contractor's License Lew.
❑ PROVIDE MFGR,INSTALLATION SPECS.
I am exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT E
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, P BUlldl
Aas provided for by Section 3700 of the Labor Code,for the performance of the work for which this PAID 0
permit Is Issued. $BIS
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of �s , �/'9
- 7 -
Compensation
o Labor Code,for the performance of me work for which This permit Is Issued.My Worker's ®� /y Lam[/ Total
CompensailonInsuranc-e carrier and Polley^"'�b�s�r pfe: �( _i 2
Carrier�' �'^� r^ I"PPoolicy No.I B D�3I3� C) 11?
.,�ER IT AUTHOR( TION DATE j
CERTIFICATE OF EXEMPTION FROM WORKERS' - IV \
COMPENSATION INSURANCE N.C.I] 6n I
(This section need not be completed if the permit Is for one hundred dollars($
100)or lees.)
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 subject to the Workers'Compensation Laws of Call- All rOOTS Shall be inspected prior to any roofing material being
fornia. I 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,alter making this Certificate of Exemption,you should become
subject to the Workers'Compensation provisions of the Labor Coda,you must forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shapes 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 roof coverings to be class"C"or better.
hereby authorize representatives or this city to enter upon the above-mentioned property for In /J //--.2 �Tt
ape tion(We)
purposes. // J1I 7
(We)agree s save,Indemnify and keep harmless the City ai Cupertino against liabilities `
judgments,costs and expenses which may In any way accrue against said City In consequence
of the granting of this permit. (SIGNATURE OF APPLICANT DATE
RE-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