R 5161 (2) PERMIT R_ 5161
APPLICATION FOR CITY OF CUPERTINO NUMBER
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 / ,,
Z Ulp ("o RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes-I understand that a Class A
NAME roof assembly is required.
NO InitI I.C.B.O.11
ADDRESS EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTO
TO BE REMOVED 70 BE RETAINED
NAME
ADDRESS/�-� �/T /A i'_� 6411 EXISTING TYPE OF ROOF COVERING
CITU dZIP ten]/ �1/, ( !H- C.�
PHONE-3>`R-S-
HONE 3>'t� 7 -7 q4 ��
BUILT-UP ROOF ❑
LICENSE ❑
NUMBER �3 ASPHALT SHINGLES /
LICENSED CONTRACTORS DECLARATION Cl/
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 lull force and
affect q s WOOD SHINGLES
License Claes Lic.Number � s�_ ❑
DateL Contrecto �� OTHER(SPECIFY) ❑
OWNER-BUILDE CLARATION -119 PROPOSED
I hereby affirm that I am exempt from the Contractors License Lew 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 a(commencing with Section 7000)of Division 3 of the UC
. 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 five hundred dollars(§500).): WOOD SHAKES
❑I,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 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.II,however,the building or Improvement
is sold within one year of completion,the owner-builder will have the burden of proving that he die OTHER(SPECIFY) El
build or Improve for purpose of sale.).
1,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 Improve$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 oma
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration;
❑I 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 ' g
permit Is Issuatt Seismic❑ have and wool the performance
Worker's Compensation the work
Insurance,as required Is I by Section 3700's SEP 11 199& �/� 0
1 _the Labor Code,for the perform and of the work for whish this permit le leeuetl.My Worker's YV1/�']
' Compensation Insurance carrier end Policy number are: Total
Carrier Policy No. I I Y I!PERMIT AUTHORIZATION DATE
V-, CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0 1
(This section need not be completed it the permit Is for one hundred dollars($100)or less.) 1.
I certify that In the performance of the work for which this permit Is Issued shell not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Cell- All roots shall be inspected prior to any roofing material being
fornoa. installed. If a roof is installed without first obtaining an
Date �l l Applicant � ��� inspection,I agree to remove all new materials for inspection.
NOTICE O APPLI NT: If,after making"tri ertiflcate of Exemption,]yWa a auto become
subject to the Workers'Compensation provisions of the Labor Code,you9ffust forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shalfbe deemed revoked. source regulations.
I certify that I he"read this application and elate that the above information Is correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof CO Brings to be class"C"or better
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purpose$.
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities,
judgments,costs and expanses which may In any way accrue against said City In consequence
• of the granting of this permit. GNA URE OFA DATE
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