R 5966 (2) PERMIT R_ 5966
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT_ / aO 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
• 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNS ' HAZARDOUS FIRE AREA
YES ❑ If yes-I understand that a Class A
NAM � roof assembly is required.
NO ❑ Initial - IA.B.O.N
ADDRESS EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS /
CONTR R'S
- TO BE REMOVED / TO BE RETAIN D -
NAM
ADDRESS TYPE OF ROOF C
CITY a ZIP EXISTING
PHONE7Ji � r�.� 3 BUILT-UP ROOF ❑
LICENSE
NUMBER A HALTSHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 8(commencing with Section D SHAKES
70001 at Division 3 of the Business and Professions Code,and my license Is In full force and
effect, � /%� WO INGLES E]License Claes Uc.Number T/ S�
Date Contractor OTHER( ) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from the Contractor's 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,orrepair any structura,prior to Its Issuance,also requires the BUILT-UP ROOF q-� ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions P"
of the Contractor's License Law(Chapter a(commancing 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 SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to Ay \\r
a civll penalty of not more than live hundred dollars($500).1:
C]1,aro owner of the property,or my employees with wages as their able compensation,will do WOOD SHAKES �' U k<-
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Praise- JJ
alone Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES
such Improveroves rments are of Iand who ntended oroffered fores such work f or sale.11,howeverh his r,,�the building or Improvement
mthat
ent G`C{ ❑
is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.),
❑],as owner of the property,am oxciusively 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 /Q f/
with a comfit explicensednrSe pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS. !
❑I em exempt under Sec. ,B 8 P.C.for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: �� 1
❑1 have and will maintain a Certificate of Consent to selLinsure for Worker's Compensation, Building
aro provided for by Section 3700 of the Labor Code,for the performance of the work for which this ^
permit Is Issued. - 10 -916
I O -`-� SeISmIC I '
❑I have and will maintain Worker' Cpensation Insurance,aro required by Section 3700 o1 _
the Lebor ode,for the performsn fon
e work for which this permit Is Issued.My Worker's Q
Compen /on Insurance terrier 8A giblicifnumb rale: Total t�8
Cer r bllcyNo, - PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0 np
(This section need not be completed If the permit Is for one hundred dollars($100)or lees.) •� S 10 -qa
I certify that In the performance of the work for which this permit Is Issued,I shall not em toy
any person in any manner so as to become subject to the Workers'Compeneatlon Laws of tau. All roots shall be inspected prior to any roofing material being
fornix' installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP P y P
with such provisions or this permit shell be deemed revoked. Source regulations.
I certify that I have read this application and state that the above Information Is correct.I agree
to comply with all city and county ordinances and stale laws relating to building construction,and All roof CON, gs to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
eDpurposes.
(We) ,x
(We)epee s save,Indemnify and keep harmless the Clry of Cupertino against liabilities,
judgme0i6,COBIe and B%penes$Which may m aey Way aCCNe aQBIOsi satl Cty a cOnBBQOeRCx
of the granting of this permit. SIS1ATURE 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
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY