R 5034 (2) PERMIT R_ 5 0 3 4
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
'
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
WI180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL � COMMERCIAL OTHER
OWNER'S /� HAZARDOUS FIRE AREA
(�'f/'y'� VES ❑ If yes—I understand that a Class A
NAME roof assembly is required.
NO ❑ Initial 1.08.0.N
ADDRESS
ls_a4_� EXISTING ROOF COVERING
PHONE
-3 G S NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S /1�
I
NAME - �/� .QIZ�'r Ll/X(Cwt ea `(_/-
TO BE REMOVED � TO BE RETAINED
ADDRESSos _ ^ TYPE OF ROOF COVERING
CIN&ZIP r7- Ct
5 3EXISTING
PHONE l'O 7 d 3 6 Z_ BUILT-UP ROOF ❑
CENSE
NIUMBER / ASPHALT SHINGLES
(162SED DECLARATION
hereby affirm Net I em licensed under provisions of Chapter (commencing caliSection WOOD SHAKES
7000)o/Division 3 01 the Business and Professions Code,and myy f license Is In lull tome and
effect, n WOOD SHINGLES ❑
License Clea �'"' LIc.Number '
Data Contractor OTHER (SPECIFY) ❑
OWNER-BUILDER DECLARATN PROPOSED
I hereby allirm that I am exempt from Iha Contractors License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,after.improve.demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF Elapplicant for such permit to file a signed statement that he is licensed pursuenl to the provisions
' of the Contractor's License Law(Chapter g(commencing with Section 7000)of Division 3 of the
Business and Professions Coda)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES �0y
6n
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).1:
C-]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 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,provided that ❑
such Improvements are not Intentletl 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(See.7044,Business and Professions Code:The Contraclore 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 contractors)licensed pursuant to the Contractor's License Law, PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 R C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
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, nd Building
as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which this '
perm) ISlsaued, 4Z9` I/ Seismic
1 have and will maintain Workers Compensation Insurance,as required by Section 3700 of
t L i or Code,for the performance of the work for which this permit Is issued,My Workers - Total
ompennaa/a/ttioon I�n ur nee/e rrier and Policf'(J�n�um�be/rJ��.
I Cerder/s—'s��(�(i,1 c�/rn `w PollcyNo. /0617 A P RMITA ITHORIZATION DAT
r' CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.] `
(This section nsatl not be completed If the permit is for one hundred dollars($100)or let ��2LdK•6. C��[/�
/��
Y 1 certify that In the performance of the work for which this permit le Issued,I shell not employ
any person In any manner so as to become Subject to the Workers'compaueatmn Laws of Can- All roofs shall be inspected prior to any roofing mateliel being
fornix. installed. If a roof is installed without first obtaining an
Date Q„(._ Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,cher making this Certificate Exemption,You should become Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Coda,You must forthwith comply PP P y p
with such previsions or this permit shall be deemed revoked. source regulations.
I certify that I have read this application and state that the above Information is correct. ngrea
to comply with all city and county ordinances and state laws relating to building construction,and All roofer t0Zbeass"C'or better
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection
judgmenpurposes. ` �
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, "\C/ J y
'
judgments,
granting of this permiexpenses which may In any way accrue against said City In consequence SIGNATURE OF APPLICANT - DAI E
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