R 5118 (2) PERMIT R_ 5118
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
.� 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
10 LP9 I &Q RESIDENTIAL—X—COMMERCIAL OTHER
OWNER'S 47 HAZARDOUS FIRE AREA
�y . YES ❑ If yes—I understand that a Class A
NAME
t� 'P.y,s'G.x roof assembly is required.
s NO ❑ Initial I.C.B.O.N
ADDRESS I Owl 1 brll,Jsp, A+_tl EXISTING ROOF COVERING
PHONE �.� O o NUMBER OF EXISTING COVERINGS '
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS
CITY&ZIP
EXISTING TYPE OF Rwf_�MI
PHONE 1 1)/IJ BUILT-UP ROOF
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRA TORS DECLARATION
1 hereby affirm that I em licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Dlvlelon 3 of the Business and Professions Code,and my license Is in full force and
effect.
License Class G_� Lie.Number
O WOOD SHINGLES ❑.
Data 9!!9 fIM Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DE RATION PROPOSED
I hereby affirm that 1 am exempt from the Contractor's License Law for the following reason.
(Sec.7031.5.Business and Professions Cotle: 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 Contrecmr's License Law(Chapter 9(commencing with Section 7000)of Dlvlelon 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 lora permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500).):
❑I,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(Sac.7044,Business and Profes.
alone Code:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES El
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) El
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 Contractors License Lew 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 v
with a contractor(s)licensed pursuant to the Convectors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Alta
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declension:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, �P/] 9 xs [� BUildin�{�(�
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this 199u
permit have and will maintain Seismic .
Ih mpen r Code,
,for the
eperformance
dorm nc of t number afor fe which this permWorker's Compensation Insurance,as it t Is Isuired sued.My Worker's Section 3700 ofI f U' UU,"ti f,f ff;kr Total
�Un � lb o�
Carrier e�� a �^r� Policy No. 11A W�y PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit Is for one hundred dollars($100)100)or leas.) Y
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 become subject to the Workers'Compensation Laws of Cell- All roofs shall be inspected prior to any roofing material being
fornla. installed. If a roof is installed without first obtaining an
Date Applicant inspection,.)agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate 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 shall be 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 rot!
f]g t CIaSS•C"Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
sp(We) purposes.
(We)agree to and
e.Indemnify and keep hay way the City of Cupertino against liabilities,
judgments,costa end expenses which may n any way accrue against said City in consequence
of the granting of this permit. S ATURE 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