R-5314 (2) PERMIT R_
APPLICATION FOR CITY OF CUPERTINo NUMBER 5 314
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
�I WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS//
G1� �, RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
,( `[ YES ❑ It yes—I understand that a Class A
NAME— /`°z c���l f� el 4L)44NO roof assembly is required.tial LC.B.O.k
ADDRESS k6 It 'Lly /L LAK EXISTING ROOF COVERING
PHONE 0372— NUMBER OF EXISTING COVERINGS
CONTRACTOR'St '
TO BE REMOVED_ TO BE RETAINED
NAME if
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP
EXISTING
PHONE BUILT-UP ROOF ❑
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
hereby iaffirmnion that em licensed under Professions
of Chapter 8(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Cotla,and my license is In full force and
effect.
WOOD SHINGLES ❑ //
License Class Lic.Number
Date Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED I\
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(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 ROOFapplic ❑
of the
tractor'or such Permit to file (Chapter signed 9(comm acinghat is licensed pursuant to the pro visions
of the Contractor's License Lew(Chapter statement(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 live hundred dol late($5001 WOOD SHAKES
Li 1,as owner of the property,or my employees with wages as their Soto compensation,will do r
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes-
sions Code:
rofes-sionsCode: 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 era 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,em 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 property who builds or Improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am mpt under B&P.C.for this reason
der WORKER'SCOMPENSATI ECLARATION APPLIC04ON(DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the owing declaration:
° ❑I have and wilt maintain a Certificate of Consent to self-insure for Worker's Compensation ��� �� t Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which ti
permit is issuetl. Seismic
C ❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of CI rryx Ur
the Labor Code,for the performance of the work for which this permit is issued.My Worker's ' t LUr•trf r(i IU�/—z��(�/a v—— Total
Compensation Insurance carrier and Policy number are:
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.
(This section need not be completed If If the the permit is for one hundred dollars($100)or less.)
certify that In the performance of the work for welch this permit is Issued, shell not employ
any person in any manner so as to become subject to the workers'Compensation Laws of Can- 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.
NOTICE TO APPLICANT: II,akar making this Certificate of Exemption
you should become Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Cotla,you must forthwith comply pP P Y P
with such provisions 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.)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 of this city to enter upon the above-mentioned property for in-
spection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, `
•judgments,costs and expenses which may In any way accrue against said City In consequence SIG OF APPLICANT DAT
of the granting of this permit.
LY
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
,1—
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