R 5300 (2) APPLICATION FOR CITY OF CUPERTINO
nNU eE a R- 5300
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
Z 6 RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
p�� ,.�� YES ❑ It yes—I understand that a Class A
NAME Z2,yam- roof assembly is required.
NO ❑ Initial I.C.B.O.N
ADDRESS - �IWM It Q EXISTING ROOF COVERING
PHOS
NE — G / 7 NUMBER OF EXISTING COVERINGS
CONTRACT R'
NAME /�e e�-sal /Pi Q ' / TO BE REMOVED TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
&ZIP 7 S' s t f �/ EXISTING
CITY
PHONE ya !Z- 27Ti BUILT-UP ROOFLICENSE
(�
NUMBER Z d ASPHALTSHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter S(commencing with Section WOOD SHAKES
7000)of Dlvielon 3 of the Business end Professions Code,and my license Is In full force and
affect. WOOD SHINGLES ❑
License Claesn3! Lia Number Y d
Data 2— Y 9 V//,w''e ContrOTHER(SPECIFY)
� actor � • �
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 9,`
construct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF 'Y\
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
• 01 the Contractor's License Law(Chaptor S(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 SHINGLES ❑
exemption.Any violation of Section 7031.5 by any applicant for a call Subjects the applicant to
a civil penalty o1 not more than five hundred dollars(8500).): WOOD SHAKES
01,as owner of the property,or my employees with wages as their sole compensation,will do PEA I D
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Protea-
' Bions Code:The Contractor's License Law does not apply to an owner of property who bullds 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.II,however,the building or Improvement
Is said 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.). (�Illl
❑1,as owner of the property,am exclusively contracting with licensed contractors to construct ,4.;.IyVNUr CUYCHIINV
the project(Sac.7044,Business and Professions Code:The Contractor's License Lew does not PROVIDE I.C.B.O.REP r1 o
apply to an owner of property who builds or Improve&thereon,and who contracts for Such projects
with a contmctor(a)licensed pursuant to the Contractor's License Lew, PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,S&P.C.for this reason
Owner Dale
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
C] OI have and will maintain a Certificate of Consent to self-insure for Workers Compensation, BUIIdIn
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this g
permit Is issued.
y1y Seismic
❑I have end will themaintain Worker's Compensation Insurance,as required by d.My
3700's 7 YYY///
the Leber Cotle,for the performance of the work for which this permit Is lasuatl.My Worker's
Compensation Insurance carrier and Policy number are: Total
Carrier .Y&W Policy No. 1 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0 /
(This section need not be completed If the permit Is for one hundred dollars($100)or lase.)
certify that In the petormence of the work for which this permit is leaned,I shall not emvjoy
any person in any manner so as to become subject to the Workers'Compensation Laws of&H. All roofs 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.
subject toEtheOWorkere Compensation tion proviafter sionis oftheicate LaborCode,you mustforthwith lbecome comply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. Source regulations.
I certify that I have road this application and state that the above Information Is correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof coverings to be class"C"or better.
hereby purposes.representatives of this city to enter upon the above-mentioned property for In. �
herebynpurposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabllltlee,
ofthe
he of this permit expensesnts,costs and which may In any way accrue against said Clty In consequence SIGNATURE 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