R 5142 (2) PERMIT R_ 514 2
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN DAYS OF PERMIT ISSUANCE OR
1 DAYS
FROM LAST CALLED INSPECTION.
BUILDING ADDRESS �^
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
\' VES ❑ . It yes—I understand that a Class A
NAME `t roof assembly is required.
n NO - Initial I.C.B.O.#
ADDRESS ' S- STEL(—�}GI . EXISTING ROOF COVERING
PHONE 4 �3 3S NUMBER OF EXISTING COVERINGS I
CONTRACTORS-
�� +rSLy✓�-•-P- C':l TO BE REMOVED TO BE RETAINED
NAME `
ADDRESS n S q TYPE OF ROOF COVERING
CITY B ZIP �/V 1 �-5 EXISTING
PHONE _r"I BUILT-UP ROOF
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSEDdunderCONTRACTORSsof Chapter 9(commencingN
hereby affirm that em Ilcensetl under fessi lone of Chapter a sIInwith f rcecand WOOD SHAKES
]000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect q 3 WOOD SHINGLES C3 Z/
License Claes C-'} 1 Llc.Number , /
Date LR Cent
License
OTHER(SPECIFY) ❑ _!S�
OWNER-BUILDER DECLARATION PROPOSED
hereby affirm that em ezwmet 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,prior to Its Issuance,also requires the BUILT-UP ROOF
applicant for each permit License flaw a signed r 9(co wnt that g it Ilcensetl 7000) fto the Provisions
of she ss and tPre sions Lew(Chapter h(commencing with Section 7000)of for the 3 of the S�Y
Business and Professions Code)or that he IS exempt antfor a and the bawls for the alleged ASPHALT SHINGLES ❑J
exemption,lAny tyof oft more ofSectionhundred
byany appllcantforepermit subjects the applicant to
e civil penalty of not more then five hundred employees
with
wag): WOOD SHAKES f
❑I,as owner of the property,or to ded oyeee with wages as their sole compensation,wolf do ❑
the work,and me structure Is not intended or offend for sale n ow er of Business end Proles-
ImpnsCotle:The,and
oes dessuch Lew does not apply toans own of property who builds or WOOD SHINGLES ❑
such
roves thereon,end who does such work offered
or through Ne own employees,Improvement that
such improvements are not intended or oHeretl for safe. ill however,the bantling or Improvement
n t ld build or I prove for purpose
s the owner-builder will have the burden of proving that he did OTHER(SPECIFY) f/ tel•(
not build or Improve for purpose of sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to construct r1 7
the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO. A J
apply to an owner of property,who builds or Improves thereon,and who contracts for such projects
with a contramore)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
I]I am exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERM
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perlury one of the following declaration:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, B
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this �$ / _
p rmf Issued. $ S IC
I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
the Labor Cotle,for the performance of the work for which this permit Is issued.My Worker's
Compensatl n Insurance carrier and Po Icy number are: Total
Carrier M�£' AMPolicy No. f° PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.I]
(This section need not be completed If the permit Is for one hundred dollars($100)of lose.)
1 certify that In the performance of the work for which this permit le le ueq I shall not employ
any person In any manner so as to become a t to the war era c eneatlon Lowe of can. All roofs shall be inspected prior to any roofing material being
forma' installed. If a roof is installed without first obtaining an
Date L Applicant inspection,I agree to remove all new materials for inspection.
NO ICE TD APPLICANT: If,alter making this Certificate of Exemption,you should become Applicant understands and will I with all point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP comply Y wanon P
with such provisions or this permit shell be deemed revoked. source regulations. -
1 certify that I have read this application and state that the above Information Is correct.l agree
to comply with all city and county ordinances and state laws relating to building construction,and Roaverbe class"C"Dr better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes.
(We)agree to save,indemnity and keep harmless the City of Cupertino Ci epalnsn liabilities,
ence
ludgmenta,costa and expenses which may In any way accrue against lead Ciry In consequence
of the granting of this permit. SIGNATURE OF APPLICANT DA E
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSPP, 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