R-5535 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R— 5535
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 ' \
S I `��j V��p �r—, RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
NAME YES [] If yes—I understand that a Class A
roof assembly is required.
` NO Initial I.C.B.O.F
ADDRESS EXISTING ROOF COVERING
j PHONE NUMBER OF EXISTING COVERINGS
CONTRACT '
l TO BE REMOVED TO BE RETAINED
NAME f
ADDRESS, C EXIING TYPE OF ROOF COVERING
CITY BZIP zI��I �� I1 C J
ST
PHONELICENSE BUILT-UP ROOF ❑
NUMBER J j ASPHALT SHINGLES El
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 �-�q r WOOD SHINGLES E]License Class Lis.Number I ✓ /�� `
Date Contractor OTHER(SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors License Law for the following reason. /
(Sec.7031.5, ,improve and Professions Code: Any city or county which requires e permit to ,^
construct,to such permit tfiledemolish,sign ed airstatement
anystructure,h prior to its issuance,also requires the BUILT-UP ROOF V
of the
applicant for such permit a lila a signed statement that he is licensed 7000)of to the provisionsof the
' of the Contractors License Law(Chapter 9(commencingisex ptwith Section 7000)of Division 3 of the
Business and Professions Code)or 031t he is exempt therefrom and the basis roe the applicant
to
ASPHALT SHINGLES
exemption.Any violation of Section 70315 by any applicant for a permit subjects the applicant io
*Zc?
a civil penalty of not more than five hundred dollars with
wag.): WOOD SHAKES
❑Les owner of the property,or to employees with wages as their sole compensation,will do ❑
the work,and the structure is not intended or offered for sale(Sea 7044,Business and mitis or
Improve.
Cotle:The,an who
License Law does not apply toensonarofproperty who buildsor WOOD SHINGLES ❑
Improves thereon,and who does such work himself or.Irough his own employees,provided that
such improvementsare not pletio ,orowoffered for sale.If,however,the building oiimprovement
t he did
nsaid build rI provyear for purposetof sthe owner-builtlerwill have the burden of provingthathatlld OTHER(SPECIFY)
not build or Improve for purpose ai sale.).
❑I,as owner of the property,am exdusivaly 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 con.ractods)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
1 am exempt under Sec. ,B 8 P.C.for this reason r
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: p
Fj I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation. P A I D Buildinl
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit Is issued.
-11 have and will maintain Worker's Compensation Insurance,as required by Section 3700 ofooQ O O Seismic
A
.,the Labor Code,for the performance of the work for which this permit is issued.My Worker's AM 2O �D t� r
�'
Compensation Insurance carrier and Policy number are: Total
•carrier Policy No. r' pERMITiAUJTHORIZATION DATE
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 lase.)
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 safe become subject to the Workers'Compensation Laws of Cali. All roof shall be inspected prior to any roofing mat rial being
fornia. installed. If a roof is installed without first obtaining an
Dates= - TApplicanl inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: IL after ng this Cerlific xemption,�ou should b oma Applicant understands and WI I Wltfl all non point
subject to the Workers'Compensation provisions C.
you m�st forihw' amply y p
with such provisions or this permit shalfbo doemetl revs 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 coveringsto b Clas rbe r.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes.
(We)agree to save.Indemnity and keep harmless the City of Cupertino against liabilities,
' of the gran costs and expenses which may in any way accrue against said City In consequence IGNATURE APPLICA DATE
of the granting of this permit.
PRE-INSPECTION: PLYWOOD: IN-PROG
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