R 5710 (2) APPLICATION FOR
CITY OF CUPERTINO NUMBER PERMIT R 5 710
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
. 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
O3O� 1 RESIDENTIAL COMMERCIAL OTHER
OWNER' - HAZARDOUS FIRE AREA
NAML�� /w��-'.�� \�I \7-^ �� YES ❑ Iroof assembly is required.
ClassA
NO InitialLC.B.O.M
ADDRESS �J` {� If EXISTING ROOF COVERING
PHONE O `J� � f4 �,1.-•J. NUMBER OF EXISTING COVERINGS I
CONTR TOR'$
TO BE REMOVED !-TO BE RETAINED
NAME --a /�7✓ 1 v�y�}p ,
. - ADDRESSqTYPE OF ROOF COV;r
CITY&ZIP -
�� EXISTING y
PHONE BUILT-UP ROOF ��(J
CENSE
NUMBER V 1 ASPHALT SHINGLES ❑ /may�3
LICENSED CONTRACTORS DECLARATION 6
I hereby affirm that I em licensed under provisions of Chapter S(commencing with Section WOOD SHAKES
7000)of Division 3 of the Busin ss and Professions Code,and my license is In lull force and
enact. U I ' /� WOOD SHINGLES ❑
License CI e �� Llc.Numbs `� "
Del, Contractor
OTHER(SPECIFY) ❑
OWNER-BUILDER D CLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason. h
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to P
construct,alter,Improve.demolish,or repair any structure,prior to Its issuance,also requires the BUILT-UP ROOF
applicant for such permit to fife a signed statement that he Is licensed pursuant to the previsions
of the Contractor's License Lew(Chapter g(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 SHINGL e ❑
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).): n'
[3 1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES 7_`4
the work,and the structure Is not Intended ores nota for Bale(Sea owner
of property
and Proles- �` AQ]
such
r "'
°Ione Code:The Conw ho d Licence Lew doe°not apply toan owner ofproperry whoidebuilds tor WOOD SHINGLES �"-A QJ
Improves othereonme ,and who does such work himself or through hi°own employees,improvement provided that
such Improveone year
are not Intended the
offered for leer,ill however,the en of pr viImprovement -
Is sold notbuwdhlnoneyearofcompletla4iheowner-bulltler will have the burden of proving that he did OTHER(SPECIFY)
not bulla or Improve for purpose of eels.).
I,as c owner of the property,am exdusNsly contracting with licensedcontractors License
L to construct
the project(Seaofprperty 7044, wa and ProfessrImprov Code:The and who
License Law does not PROVIDE LC.B.O.REPORT NO.
apply to c contractor(s)
owner of property whobuildst or Improves thereon,entl who contracts for such projects
with am
under See.
to the Contractors License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑1 em exempt under Sec. ,BSP.C.for this reason
Owner Dela
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: - /
❑ have and willmaintaina of the
Labor
Consent to sell-insure for of
work
Compensation,hickth �I � ^� .1/5)
��� Buildintd�
as provides lardy ill main ain a o1 the Labor Cotle,for the performance r of the work for /~1' 1
permit Is Issued Seismic
1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 0l
the Labor Co ,for the eaormance of the work for which tll�s py�I I e �gy.�orJtere Total
Compen nsurance carr r and Policy number are: Y 1/ �°��l.t S'�,
Carrier Policy No, CJ PERMIT AUTHORIZATION D E
RTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.E]
(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 far which IhIs permit Is Issued,I shell not employ
any person In any manner so as to become subject to the Work Co eneegdn Laws of can- All roofs shall be inspected prior to any roofing material being
f.his, � Q �p installed. If a roof is installed without first obtaining an
Dat?2 ppncant ('W�J� ° "�/"'tAfY N inspection,I agree to remove all new materials for inspection.
NOTICE O APPLI ANT: If,°Her making this Certificate of Exemption,you should become Applicant understands and will comply with all non point
subtest Id ih Workare'Compeneellon rovlslons of the Labor Code,you must forthwith comply PP p y p
with such provisions or this permit ehslQbe deemed revoked. Source regulations.
I certify that I have reed 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 buildingconstruction,end AD- ef-COVBIIngS(t0 be CIBSS"C"Or better.
hereby authorize representatives of this city to enter upon the above-mention I property for in. 11
specdon purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino 8aalnet Ilabllltlee,
judgmenle,caste and expanses which may In any way accrue against said Clty In consequence
. of he grentmp of th permit. SIGNATURE OF APPLICANT 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
OFFICE COPY