R 5983 (2) PERMIT R_ 5983
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1W DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS /J
/0 SLcok A110 r 441 ,
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
T / YES ❑ If yes-I understand that a Class A
NAME_ _ / 10 a T roof assembly is required.
NO ❑ Initial I.C.B.O.0-
ADDRESS——qlz a V)-1 t, EXISTING ROOF COVERING
PHONE - NUMBER OF EXISTING COVERINGS
CONTRACTO/F
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS ///� ��y //J /,z �I� TYPE OF ROOF COVERING
CITY&ZIP �p!• 7-�==/ / ( �O CL/S /'
EXISTING
PHONE BUILT-UP ROOFLICENSE
❑
NUMBER ASPHALT SHINGLES ❑
LIC SE CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with S t WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect.
C 3q „Z(��j� 3p WOOD SHINGLES ❑
License Class Lic.Number
Date Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I Am 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,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 f�
of the Contractor's License Law(Chapter 0(commencing with Section 7000)of Division 3 of the 91
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
a civil penalty of not more than five hundred dollars($500).1:
❑ WOOD SHAKES
1,as owner of the property,or my employees with wages as their sole Compensation,will do
the work,and the structure is not intended or offered for sale(Sec.7044,Business and Profen- I
stens Code:The Contractors License Law does not apply to an owner of properly who builds or WOOD SHINGLES ( LV
Improves thereon,and who does such work himself or through his own employees,provided that r
such Improvements are not intended or offered for sale.If,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) Elnot build or improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractors License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑1 em exempt under Sec. ,B It P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration;
❑I have and will maintain a Certificate of Consent to self-insure for Workers Compensation, Building
as provided for by Section 3700 of the Labor Code,for the pedggnance of the work for which this
permit Is issued. L/O - I I - ID Seismic I.
❑ have and will the pelf Workers Compensation Insurance,as required by Section 3700 of V 7 �� Q o
Comps or Code,for the performance of the work for which this permit Is lasuetl.My Workers /JO Total Ian$.
Compa�sspIyion�,sInsurance farrier an./tl�J�'Il�c(y/��um�b/erprq; a. /���c—�
Carrier •��l�r��'�'/ ; 4+/yel' �0/spollcy.No.-�-�c�t(p���� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑ OD - 11 -99 I I �C�
ta a
(This section need not be completed If the permit Is for one hundred dollars($100)or leas.) �O Q
I certify that in the performance of the work for which this permit is Issued,I shall not employ
any person In any manner so as to became subject to the Workers'Compeneatlon Laws of Can- All roofs shall be inspected prior to any roofing material being
forma' 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: If,alter making this Cortices of Exemption,you should become
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply Applicant understands and will comply 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 Is correct.I 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-mantloned property for In-
apectlon 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 SIGNATURE OF APP66" /J
of the granting of this permit. 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