R-5891 (2) PERMIT
APPLICATION FOR CITY of CUPERTINO NUMBERR_ 5891
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
ONER'S HAZARDOUS FIRE AREA
YES '❑ If as—I understand that a Class A
N E D9 C.- 9 C''Y' roof assembly is required.
NO1!0912
Initial I.C.S.O.ff
F02ADDREss r��' a �— EXISTING ROOF COVERING
PHONE .5-3 ^ NUMBER OF EXISTING COVERINGS T
CONTRACTO 'S
7-- TO BE REMOVED TO BE RETAINED
ADDRESS
� � G �r T
TYPE OF ROOF COVERING
CIN BZIP _�L F lJ
EXISTING
PHONE 700p BUILT-UP ROOF ❑
LICENSE �+ /
NUMBER ASPHALT 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 is In full force and.
effect' // WOOD SHINGLES
License Class Lic.Number T� O
Date Corr far. �d��J� OTHER(SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED
1 hereby affirm that I am exempt from the Contractors 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 21"
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 - _l
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES U`X/
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).): WOOD SHAKES ❑
I,as owner of the property,or my employees with wages as their sola compensation,will do
the work,and the structure Is not Intended or offered for Safe(Sec.7044,Business and Profes.
slons Code:The Contractor's Licenaa 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-bultder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
O I,as owner of the property,em 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 on owner of property who builds or Improves thereon,and who contracts for such project.
with a contractor(s)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 Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to sell-insure for Workers Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit Is Issued. Seismic
❑1 have and will maintain Workers Compensation Insurance,as required by Section 3700 of
the Labor Code,for the performance of the work for which this permit Is issued.My Worker's ` ` 1 M�
Compensation Insurance carrier and Policy number are: -ox, �,/`p` -` , Total
Carrier Policy No. PfERMI UTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.p /
(This section need not be completed it the permit Is for one hundred dollars($100)or lass.)
I certify that In the performance of the work for which thl permit is Issued I shell not employ
any person In any manner so as to become subjec t or+ @r�ny�{ahiv*of call- All roofs Sha be inspected prior to y roo Ing mat i eing
forma. _-''//� installed. If a roof is installed without first obtaining an
oat S�3 "� Applicen o inspection,I agree to remove all new materials for inspection.
subjectNOTI.the Worrkers'C ComCE TO APPLICANT:pensation provisions of thecate of Labor Code,you mustuforthwlith comply me Applicant understands and will comply with all non point
with such provisions or this permit shalljbe deemed revoked. source regulations.
I certify that 1 have read this application and state that the above Information is correctI 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-mentioned property for in.
erection purposes. .S- ... CT_
(We)agree to save, Indemnify and keep harmless the City of Cupertino against liabilities, cl � ^ CJ
judgments,costs and expenses which may In any way accrue against said City In consequence $IGNATU E OFAPPLICANT,- DATE
of the granting of this permit.
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