R-5415 (2) I �,t
r
APPLICATION FOR CITY OF CUPERTINO
nNUMBER R' 5 415
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 //(�
" „ D Sii � 1 ��� ba. RESIDENTIAL COMMERCIAL OTHER
OWNER'S`],`/�yy�y /M� - HAZARDOUS FIRE AREA
10 NAME 0 • _" JG�� • �I UO X� y % VES ❑ Imf assembly is rengquh�eClassA
NO InNal I.C.B.O.#
ADDRESS y M -EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS
PHONE
CONTRACTOR'S {� D
NAME C A .Yl TO BE REMOVED TO BE RETAINED
ADDRESS PE V
CITY&ZIP
EXISTING
PHONE ` BUILT-UP ROOF ❑
NUMBER ASPHALTSHINGLES ❑ �O�
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(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 ❑ S`�
License Claes Lie.Number
Dale Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED A
I hereby affirm that I em exempt from the Contractor's 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 ROOP9806 0 ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions ^/
of the Contractor's License Law(Chapter g(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SF�hgJ ES �('n�❑
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to `. 4
a civil penalty of not more than five hundred dollars(55001): WOOD SHAKES `Ft
E]1,as owner of the property,or my employees with wages as their sole compensation,will do f/�4A' El
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profen. Np ❑ , -+ ��
lions Code:The Contractor's License Lew does not apply to an owner of property who build$or WOOD SHINGLES 1L.15C`X^W'
mproves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for sale.It,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) ❑
fthpl.'].
or Improve for purpose of sale.).
s owner of the property,am exclusively contracting with licensed contractors to construct
ct(Sec.7044,Business and Professions Cotle:The Contractors License Lew does not PROVIDE I.C.B.O.REPORT NO.
to an owner of property who builds or improves thereon,antl who contracts for such projects
contractor(s)licensed pursuant to the Vneactor'e ucenae Law. PROVIDE MFGR.INSTALLATION SPECS.
Impl untler Sec. ,B 5 P.C�for this reason
owns Dr
WORKER'S COMPENSATION DERATION L
APPNC TION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑l have andwlll maintain a Certificate of Consent to sell-Insure for Workers Compensation, 11 Building
as provided for by Section 3700 01 the Labor Code,for the performance of the work tar which this P
permit is lve and r $BISRIIC
❑I haus end will maintain Worker's Compensation Insurance,as required by Section 3700 of T
_the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's Cir Ur O Total
Compensation Insurance carrier and Policy number are:
(,VH� - O O
Carrier Policy No. PERMI AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C. �w /,
(TMs section need not be completed It the permit ic for One permit
is
sued,I shall not
lasso
I pertly them the performance 01 the work for which W permit is Issued. shall not employ
any parson In any manner so as to become subject to the Workers'Compensellon Laws of Cell- All roofs shall be inspected prior to any roo ng material being
forma. 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,alter making this Certificate of Exemption,you should become A licant understands and will nnI with all non oint
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pp p y p
with such provisions or this permit shafgbe deemed revoked. source regulations.
I certify that I have read this application and state that the above Information Is correct.)agree
to comply with all city and county ordinances and state laws relating to building construction,and I roof coverings to be cla bettegr
hereby authorize representatives of this city to anter upon the above-mentioned property for In. + / \
speclion purposes.
(We)agree to Save,indemnity and keep harmless the City of Cupertino against liabilities, V
judge granting of this expenses
mit.es which may In any way accrue against said City In consequence SIGNATUR�OF APPLICANT DATE
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE_ INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE INSP. DATE INSP. DATE
Co^
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED"FOR INSPECTION
OFFICE COPY