R 5015 (2) PERMIT R_ 5 015
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF.PERMIT (406)777-3226 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1B0 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
O/ Q'C� RESIDENTIAL COMMERCIAL OTHER
OWNERS //��/I Z_
HAZARDOUS FIRE AREA
NAME 1/f/1 rLo_ YES ❑ If yeas I assembly
is req that. Class A
roof assembly is required.
NO ❑ Initial I.C.B.O.fl
ADDRESS {.�hQ d.S �+ d uV '� EXISTING ROOF COVERING
PHONE
�j / NUMBER OF EXISTING COVE[iINGS
`JYv/
CONTRACTOR'
S / //'� �//'J
NAME f Q S V -S /�,. Q Q / iJ u - TO BE REMOVED TO BE RETAINED
tCDRESS /76 R O / 1�'71� TYPE OF ROOF COVERING
CITV 8 71PP6 . 6 e.J / <
LO-5 V5 C),3 EXISTING
PHONE BUILT-UP ROOF ❑ . 5X
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 Divlslon of the Business and Professions Code-and my license to I lull force and
effect. /�
_V /�i� 7 WOOD SHINGLES ❑
Llcense Claes Lic.Number—
O ❑
Date Contractor OTHER(SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from the Contractor's License Lew for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
Construct,altar.Improve.demolish,or repair any structure,prior to its Issuance,also requires the BUILT-UP ROOF El
for such permit to lila a signed statement that he Is licensed pursuant to the provisions
of the ss an Pro License Lew(Chapter h(commenting with Section 7000)of Dfor the 3 le the
ex
Business end violation of Code)or that he Is exempt Therefrom and the Besse for the alleged ASPHALT SHINGLES
exemption.Anyviolationo t more
of Section hundred
by any s($ 0 applicant for a permit subjects the applicant to
e dull penalty of not more then flue huntlred dollen($500)J:
01,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-
sions Code: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 ere 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) ❑
not build or Improve for purpose of sale.).
D I,as owner of the property,am exclusively contracting with licensed contmators 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 contracts for such projects
with a contmclugs)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS. S fP
❑1 am exempt under Sac. ,S a P.C.for this reason
160-
Owner Date WORKERS COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: r. ♦, ;T
❑I have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, l� Building __((/[•[ ,)���
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
erml elseuetl. 11fa �(�(tC ��� $eISR11C
ave end will maintain Workers Compensation Insurance,as required by Section 3700 a1 Vl3 JJO
.,th Labor Cotle,for the pedormence of the work for which this permit In Issued.My Worker's
Compensatl 7lnsur nce ler entl Policy number are: Total
Carrier FROMNo. vPERMI THORIZATION DATE
t CERTIFCO OF EE T10N INSURANCE
FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed If the permit is for one hundred dollars($100)or leas.)
I certify that In the performance of the work for which this permit Is Issued.I shall not employ 404
any person In any manner ad as to become subject to the Workers'Compensation Laws of Cali. All oo..shall be inspected prior to any roofing material being
fornia. installed. If a root is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It after making this Certificate of Exemption,you shoutd become Applicant understands and will coin
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply ply with all non point
with such provisions or this permit shalCbe deemed revoked. source regulations.
I certify that I have read this application and state that the above information le correct,I agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof Coy i gs to be class"C"or better.
hereby authorize representatives of this clry to enter upon the ebovementlonad property for In-
sp purposes.
(We)
(We)agree s save, sews lw and keep harmless the City ai Cupertino against Ilabllltlea, s O 6
judgments,the gran costa and expenses which may In any way accrue against uitl City in consequence
' ofihegrangngothis pprmll. SIGrTA1 URE OFAPPLICANP' 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
13FFIrF VOPV -