R 5557 (2) r'
PERMIT
If r APPLICATION FOR CITY of CUPERTINO NUMB R R- 555
7
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 190 DAYS OF PERMIT ISSUANCE OR
190 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
G� � VES ❑ If yes-I understand that a Class A
NAME �C.MJ roof assembly is required.
J NO I Initial I.C.B.O.k
ADDRESS_ � �J — EXISTING ROOF COVERING
( '
PHONE 5 (O/ r / / O U NUMBER OF EXISTING COVERINGS /
CONTRACTS _
/ TO BE REMOVED TO BE RETAINED
NAME _
ADDRESS -41 Oq �^— Ck4t / TYPE OF ROOF COVERING
CITY&ZIP_/R-t-�o Q/ 4.� /�.36 tG
/, �� EXISTING
PHONF40� t �n`7Yi-�7Z3 '-6L3 7 3 BUILT-UP ROOF ❑
CENSE
NUMBER d� {-OASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license la In full force and
seem' WOOD SHIN ❑
License Class ��� .492- 700 Lic.Number
ot
Date D contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLAR N PROPOSED '
A
I hereby affirm that I am exempt from the Commctor's License Law for the following reason. A
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to P I D
construct,alter,Improve,demolish,or repair any structure,prior to its issuance,also requires theBUILT 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 Section 7000)of Division 3 of the D pp-
Business and Professions Code)or that he IS exempt therefrom and the basis for the alleged ASPHALT SHING R d
lei 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).): C ` I lAx�. 1'
❑1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKEti(fY Ut- l.url:rgf t '/ LLd L.
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Proles- 13alone Code:The Contractor's License Lew 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.).
Ll I,as owner of the property,am exclusively contracting with licensed contractors to construct �. D S�fo�
the project(Sec.7044,Business and Professions Code:The Contractors Z
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 Law. PROVIDE MFGR.INSTALLATION SPECS.
E]I am exempt under Sec. ,B 8 P.C,for this reason
owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: C
❑1 have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, i 1 /�—
asprovldedforbySeclion3700oftheLaborCode,for the performance of the work for which this /� O) Building l
p 11Is hlveaed. 3/ 7 i2J SSv Seismic -
I have and will maintain Workers Compensation Insurance,as required by Section 3700 of YYCC
he Labor Code,for the performance of the work for which this permit Is Issued.My Worker's
Compensation In ranee terrier and Policy number are: Total
Carrier� �wA Policy No._6_7/ -rj2-UZS PERMIT AUTHORIZATION DTE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.]
(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 for which this permit Is Issued,1 shell not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Cell- All rOOfs shall bOinspecied prior to any roofing material being
fornia. 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,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 shalGbe 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 Covering class or better.
hereby authorize representatives of this city to anter upon the above-mentioned property for in.
spection purposes. -
(We)agree to save,indemnify and•keup harmless the City of Cupertino against liabilities, 3
judgments,costa and expenses which may in any way accrue against said City In consequence
nt the granting of this permit. SIGN TUBE OF PPLICANT DA E
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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY