R 5193 (2) • PERMIT R_ 519 3
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
'
WITHIN DAYS PERMIT ISSUANCE OR
WI DANSS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
�o,t'e.r M,c.ct'>'L �✓�. Cu AaxT„so C�.u�CC�
RESIDENTIAL COMMERCIAL OTHER
OWNER'S fien( /4�- (/1 �/��/ HAZARDOUS FIRE AREA
NAME 1rrAA�71l C4uil oC CII/'OM�noa NES ❑ If yes—I Understand that a Class
E*,,,,Wf assembly is required.
NO Initial I.C.B.O.
/•y,/� W
ADDRESS ” •f LL&-?L Xyt, rill 0;l 0 EXISTING ROOF COVERING
PHONE Zr?- 1
— / 14 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
G L\S Al a� TO BE REMOVED E TO BE RETAINED
NAME
ADDRESS TYPE OF ROOF COVERING
CITU 8 ZIP EXISTING
PHONE BUILT-UP ROOF
LICENSE
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000) El
Division 3 of the Business and Professions Code,and my license is In lull force and WOOD SHINGLES ❑
License Class Lic.Number
Date Contractor
OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors License Law for the following reason.
fSec.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 ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
• of the Contractor's License Law(Chapter 9(commencing with Section 7000)o1 Division 3 of the
Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES [3�
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($501 WOOD SHAKES
❑I,as owner of the property,or my employees with wages as their sole compensation,will do ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Proferi
alone 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 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.).
❑1,as owner of the property,am exclusively 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 properly who bulids or improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant o the Contractors License Law. PROVIDE MFGR. INSTALLATION SPECS.
❑1 am a mpt under�ec. ,B 8 P.C.for this reason
owner VTORKill COMPENSATION DECLARATION APPLICATION DATE1 VALUATION PERMIT FEE
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, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this pp ' DOD �� g
permit is Issued. A I D ' Seismic
❑I have and will maintain Workers Compensation Insurance.as required by Section 3700 01
.,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: ((�7�1y Total
Carrier Policy No. CITY
' IT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM
COMPENSATON INSURAN EWORKERS' NCD CIy r CJUfi
(This section need not be completed If the permit is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this permit Is Issued,I shall not employ 1•
any person In any manner so as to become subject to the Workers'Compensation Laws of Cali. All roofs shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTsubjecttoo thee Worrkera'Compensation prrovisionCE TO APPLICANT: If.aftmakins of the�Labor Code,cate of Exemyolu must forthwion,you tlhbecome comply Applicant understands and will comply with all non point
with such provisions or this permit shall deemed revoked. source regulations.
1 certify that I have read this application and state that the above information Is Correa.I agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof coverings to class"C"Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes. . L
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, �Q� :
judgmenta,costs and•
of the granting of this permit.es which may In any way accrue against said City Inconsequence SIGNA RE OFFPLICANT DATE
PRE-INSPECTION: PLYWOOD: I -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