R-5378 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBERR_ 5378
INSPECTION DIVISION PERMIT EXPIRATION
• REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
• BUILDING ADDRESS
/ RESIDENTIAL COMMERCIAL OTHER
OWNER'S / HAZARDOUS FIRE AREA
'{....sC.� O/ \ VES rl r yeas I understand that, Class A
NAME `{._.kC�� 4{ roof assembly is required.
- NO L Initial LC.B.O.#
ADDRESS Q_ EXISTING ROOF COVERING
PHONE NUMBER OF EXISTIN9 COV RINGS
CONTRACTOR'S '///���
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS <^`o ,,,,�� �� �^,� TYPE OF ROOF COVERING
CITY&ZIP— �Jrn`�'
��os•� � - y EXISTING
PHONErl BUILT-UP ROOF 13LICENSE
NUMBER - ASPHALT SHINGLES J
LICENSED COITMACTOFIS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Divisio 3 of the Business and Professions Code,and my license I In 1 1 to ce and
effect.
WOOD SHINGLES
License Class Lic.Number x
OTHER(SPECIFY) ❑
Data Contractor `
NER-BUILDER DECATION PROPOSED
hereby affirm that em exempt from the Contractor's L ansa Lew for the following reason.
(Sec.7031.8,Business and Professions Code: Any city or county which requires a permit to
applicant
improve,to file signed statement that
prior coIts issuance,also regmresthe BUILT-UP ROOF
applicant for such permit to file a signeddr 9(commencing
comm that he is licensed7000)pursuant to the Provisions
of sin ssand
Contractor's License Lew(Chapter 9 is ex a pt t with Section 7000)of Division 3 of the
Business antl Pmflation f Code)or that he Is exempt therefrom and the base for the scant to ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit eublects the applicant to
e civil pastry a not more than live hundred dollars(Sih ): WOOD SHAKES
1,as owner ofthe property,ar to employees with wages astheir sole compensation,will s- ❑
the work,and the structure is not inlantletl or offered for sale(Sec.7044,Business end Profes-
sions Code:The Contractor's License 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 awn employees,provided that
such Improvements are not intended or offered for sale.If,however,the building or improvement
IssoId within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) Elnot build or Improve for purpose of sale.). -
I,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 improves thereon,and who convect.for such projects
witly.� ntractons)licensed pursuant to the Contractor's License Law. PROVIDE MFGR. INSTALLATION SPECS.
VNkm exempt under Sec. ,B&P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of penury one of the following declaration:
I have and will maintain a Certificate of Consent to self-insure for Workers Compensation, Buildin
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. ® I Seismic 1
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700of
the Leber Code,for the performance of the ware for which this permit Is Issued.My Worker's
v 'x{RIL v��(� Total
Compensation Insurance terrier and Polity number are 0/1V
Carrier Policy No. °PERMIT Xbki6bRIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.[]
(This section need not be completed If the permit is for one hundred dollars(8100)or less.)
I certify that in the performance of the work for which this p rmit Is isuad,1 shall not employ
any person In any manner so as to b a apt tonne ars Compensation Laws of Car. All roofs shall'be Inspected prior to any roofing materi I b mg
fornia. installed. If a roof is installed without first obtai ing an
-' ppll t inspection,I agree to remove all new materials for inspection.
NOT subject foEheOWorkersCompensetlonpro si nme
isoftheCtiflLabor ` de,youtik�nmusfuloto�bempty Applicant understands and,will comply with all non point
with such provisions or this permit shall b deemed revoked. Source regulations. l�
I certify that l have read this application nd state that the above Information is correct.I agree �/
to comply with all city and county ordinanc s and state laws relating to building construction,antl OV rift s a lass"C"or to .
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes. /
(We)agree to save, Indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may In any way accrue against said City in consequence U E A DATE
of the granting of this permit.
PRE-INSPECTION: PLYWOOD: IN-PROGRS:
INSP. DATE INSP.-DATE- it 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