R-5315 (2) APPLICATION FOR CITY OF CUPERTINO PERMIT
u B R R- 5 315
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
RESIDENTIAL COMMERCIAL OTHER
OWNER' HAZARDOUS FIRE AREA
�� A ,7 YES ❑ If yes—I understand that a Class A
NAME / m 0 A R NO roof assembly is required.
Iniial I.C.B.O.If
ADDRES" QV!�tiPALM A 1Z/ - EXISTING ROOF COVERING
PHONE m C/( Zz O NUMBER OF EXISTING COVERINGS
CON TRAC OR'
./1 /, 4 �ONT9;,1 vs-Fro TO BE REMOVED TO BE RETAINED
NAME_— (- L L/� L
ADDRESeE OF ROOF COVERING
r" CITY a ZIP 19 s--o L�4 7 .ti . .K Vl� EXI TING
x PHONE IN 151 17 ,0 BUILT-UP ROOF ❑
LICENSE
NUMBER 2 ASPHALT SHINGLES Ly]
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ❑ �L J
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and F
Life`s WOOD .S
License Class�_ Lia Number 7- SHINGLES
❑ 7`
Date ! Contractor T �aN5Zbz0 OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
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 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 Sectian 7000)of Division 3 of tha
• 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 live hundred dollars($500).j: WOOD.SHAKES
E]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 Profes-
sions Coca:The Contractors 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.).
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 contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICATIO 15ATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
haby affirm under penalty of perjury one of the following declaration: e,
ve and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, Cf'T •v Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is Issued. GF Seismic
❑I have and will maintain Workers Compensation Insurance,as required by Section 3700 of �. f
_the Labor Code,for the performance of the work for which this permit Is Issued.My Workers Gy`(Lti 1 S{r_b6 Total
Compensation insurance carrier and Policy number are: , 001��� �- _` J�
Carrier �ZGT�Tr/Al� Policy'a %�"' PERMIT AUTHORIZAT DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed if the permit is for one hundred dollars($100)or leas.)
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 Can- All roof.^shall be inspected prior to any roofing material being
fornix. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
subject 2 the WorrkersE TO e'Compensation provisionls of theecate I-aborof Exemption,Code,you mustuforthwiithbcomply Applicant understands and will comply with all non point
with such provisions or this permit shelCbe 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 r coverings to be las "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, �j 1' 7
judgments,costs and expenses which may in any way accrue against said City in consequence
•
of the granting of this permit. qIGNATURE OF A P C NT DATE
PRE-INSPECTION: PLYWOOD: IWPROGFISS:
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
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