R 5759 (2) APPLICATION FOR CITY of cUPERTINo
NUMBER ERMIT R- 5759
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(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/ v/
RESIDENTIAL COMMERCIAL OTHER
OWNER'S I HAZARDOUS FIRE AREA
t
�/ /��-r//� VES ❑ If yes s I understandisreq that. Class A
NAME_ �rg� � roof assembly is required.
NO ❑ Initial— LC.B.O.It
ADDRESS Z �4� EXISTING ROOF COVERING
PHONE _ NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
� TO BE REMOVED TO BE RETAINED
NAME—
ADDRESS ( y TYPE OF ROOF COVERING
CITY&ZIP �my EXISTING
PHONE zgG– ��/ BUILT-UP ROOF ❑
LICENSE
SHINGLES
6Z ILLICEN CONTRACTORS DECLARATION
1 hereby affirm that I em licensed under provisions of Chapter B(commencing with Section WOOD SHAKES
7000)of Divlelon 3 0l the Business and Professions Cade,and my license Is In lull lone and
effect,
6_24_
�s WOOD SHINGLES
License Clea Llc.` '((�jJ4 Number r
Date (n_ Comreclor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATI PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sac.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 Lite a signed statement that he Is licensed pursuant to the provisions ❑
of the Contractors License Law(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 SHINGLES ❑
rzemplion.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of net more than five hundred dollars($500).):
❑1,as owner of the property,or my employees with wages as their Bale compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profen
sions Code:The Contractor's License Law does not apply to an owner of property who builds orimproWOOD SHINGLES
Suchl pmvomenn,thereon,s are
whodoes ndedsuch or ofrk fered self or frSalehrouoweeown employees,providImprovement
Is
❑
such Improin one year
are not completion,
leb n,oro wnor for seer.illt.however,the buiburden
pr or Improvement
not ld bull or
prove for purpose
sthe ownerbulltler will have the Owtlen of Droving that he tlld OTHER(SPECIFY)
❑ ,
not build or Improve for purpose o/sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Coda: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 Contradicts)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
1 hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, Building
ae provided for by Section 3700 of the Labor Code,for the performance of the work for which this �DL!'1A�� g
permit Is issued, JUN
1 tl�( D C'~�� Seismic
❑I have end will maithe pert Worker's Compensation the wokfor Insurance,as required su Section 3700's H V rV d. AND
the Labor Code,for the performance of the work for which this permit la Issued.My Worker's
Compensation Ineurande tattler and Policy numb are: ( Total
Carrier Policy No. PER ._T HORIZATION DATE
CERTIFICATED EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N,C.�
(This section need not be completed If the permit Is for one hundred dollars(5100)or leas.)
I certify that in the pedormance of the work for which this permit Is issued,I shell not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Cali. All roots shallbb inspected prior to erny roof ng nMtbpd being
fornia. installed. If a roof is installed without first obtaining an
Date Applicantinspection,I agree to remove all new materials for inspection.
NOTICE subject to theOWorrkers'Compefnaetleon provisionis of theflcate Laborr Coda,you mustfothwith comply Applicant understands and will comply with all non point
with such provisions or this permit shaNbe doomed revoked, SOUfCe regulations.
I certify that l have read this application and state that the above Information Is correctI agree
to comply with all city and county ordinances and stele laws totaling 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,Indomnity and keep harmloss the City of Cupertino against liabilities, 4 I
judgments,costa and expenses which may in any way accrue against said City In consequence
of the granting of this permit. $IGNAT LM E OFA T ATE
• PRE-INSPECTION: PLYWOOD: IN- ROGRESS:
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