R 5957 (2) PERMIT R_ 5957
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
ft
REROOF PERMIT n y e)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
G WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
O e RESIDENTIAL COMMERCIAL OTHER
O NE/R/',S� n HAZARDOUS FIRE AREA
NAME` Mn2 Q/I C A T C� ( H' L YES ❑ If yea s I assembly
is understand that a Class A
_/_✓Z root assembly is required.
NO CIInlbal I.C.B.O.g
ADDRESS J L �j17 &45do UP ' SO�� EXISTING
PHONE d S— �Q� NUMBER OF EXISTING COVERINGS
CONTRACT R'S -
NAME H TO BE REMOVED TO BE RETAINED
ADDRESS
OS iT TYPE OF ROOF COVERING
Clry a zlP / c s _=V
EXISTING
PHONE BUILT-UP ROOF ❑
LICENSE '
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under pro I he of Cheptpppr B(commencing with Section WOOD SHAKES
7000)of DIvl6lon 3 0l the Business and Prelesslons Code,erlp my Ilcense le In full force and
anent' / WOOD SHINGLES El
License Claes 44;U Lid.Number
Date Contractor
TH (SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED .
I hereby affirm that I am 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,or repair any structure,prlorto 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 Low(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 SHINGLELS\ �or0'
exemption.Any violation of Section 7031.5 by any applicant for e permit subjects the applicant to av `
a civil penally of not more than five hundred dollars($500).):' WOOD SHAKES Q`G
❑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 Proles.
sons Code:The Contractor's License Law does not apply to an owner of property who builds or
Improves thereon,and who does such work himself or through his own employees,provided that WOOD SHINGLESC ❑
such improvements are not Intended or offered for sale.If,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) ❑
not 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 Contranors 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 am exempt
under
a pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑I em exempt under Sec. ,B 8 P.C.for this reason
Owner Date
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 Coce,for the performance of the work for which this
permit Is Issued. _Q^ ///'''��� Seismic
❑I have and will maintain Workers Compensation Insurance,as required Is I by d.My Worker's of U� I"1 1 a �i0(J
,the Labor Cotle,for the performance of the work for which this permit la Issued.My Worker's IyR
Compenaatl Insmence carrier and y num�mbe�are--- uG Total
Carrier lAi«_ 1ldr�:/tiolcytt 567 /J,. pERMITAUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C. T
(This section need not be completed It the permit Is for one hundred dollars($100)or lose.) UOQ A T-0, 01 -)',_%
I certify that In the performance of the work for which this permit Is Issued,I shall not e
any person in any manner so as to become subject to the Workers'Compansatlon Laws ofmploy Cali. All roofs shall be inspected prior to any roofing material being
farnia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
subject NOTICE the WorkereCCompef,after nsation provisionis ofethelcate of Laborr Code,you mustforthwith lbecome
comply Applicant understands and.will comply with all non point
with such provisions or this permit shaNbe deemed revoked. SOUrCe legUIBIIORS.
I certify that I have read this applicatlon and elate that the above Information Is correct.I agree
to Comply with all city and county ordinances and state laws relating to bulltling construction,and All roof cove ' to be class`C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property Mr in.spection purposes. _ 7_/6�
(We)agree to save,Indemnity and keep harmless the City of Cupertino against Ilabllltlee, ,6�' `
judgments,coats and expenses which may In any way accrue against said CityIn consequence
of the granting of this permit. 51UNAi IJHF OF AP CA 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY