R 5148 PERMIT R_ 514 8
APPLICATION FOR CITY OF CUPERTINO NUMBER
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
I5—'IL L4 RESIDENTIAL COMMERCIAL OTHER
OWNERS'n � - HAZARDOUS FIRE AREA
Y 1 1 1 1 nye ry �'!p VES ❑ If yes s I understand that a Class A
NAME I I n a Dyen L root assembly is required.
I ff NO ❑ Initit
ial I,C.B.O.#
ADDRESS-2`i 5-7`i �Qywr EXISTING ROOF COVERING
PHONE 3 ^o�g 14'' / x NUMBER OF EXISTING COVERINGS \
CONTRACTOR'S
NAME TO BE REMOVED TO BE RETAINED
ADDRESS II ^^ SIC'} OV
CITY BZIP_1 `-w
G+-� n EXISTING
PHONE— _ V I t 0� BUILT-UP ROOF ❑
LICENSE
NUMBER J59_15CGA ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensee under provisions of Chapter 8(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
affect. WOOD SHINGLES ❑
License Class e c Llc.NuEM4m
Date contract OTHER(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 ..
canetruct,alter,Improve.demolish,or repair any structure,prior to Its lssuanco,also requires the BUILT-UP ROOF 13applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractors License Law(Chapter a(commencing with Section 7000)of Division 3 of the y"
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLa-
a
p 9 1C
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to r
a civll penalty of not more than five hundred do as($500).): S^
01,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES _fE1`0
the work,and the structure is not Intended or offeree for sale(Sec.7044,Business and Proles.
sions Code:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES
improves thereon,and who does such work himself or through his own employees,provided that El
such Improvements are not Intended or offered for sale,ll,however,the bulltling or improvement
is sole within one year of completion,the owner-bullder will have the burden of proving that he the OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑1,as owner of the property,em exclusively 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
with a contractors)licensee pursuant to the Contractor's License Law. PROVIDE MFGR. INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: /O ^_
❑1 have and will maintain a Certificate of Consent to 8011-insure for Worker's Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit lsIssued.
Li the pSeismic •�a
have and w111 elrf Worker's Compensation Insurance,as required by Section 3700 of
the Labor Code,for the performance of the work for which this permit Is Issuetl,My Worker's /O 7
Compensation
��InsJuresnce cerrley�r teq�n}d`Policy number are: ^� (] UNIt �✓ Total
Carrier S.)I `�1/T'� IYN Policy No.ds�-V(O C�T71�-CJ PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE ,0)9 Q G�
(Title section need not be completed If the permit Is for one hundred dollars($1100)or lase.)
I certify that In the performance of the work for which this permit is Issued,I shall not employ
any person in any manner so as to become subject to the Workers'Compensation Lowe of Can- All roofs sit a inspected prior to any roofing material being
(orals' installed. If a roof is installed without firstobtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
subject to the Workers'Compef,after ne melon prrovisions ofethe11cate of Labor Code,Exemption,
must forthwith become
comply Applicant understands and will Comply with all non point .
with such provisions or this permit shell be deemed revoked. source regulations.
1 certify that f have read 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 1l roof coverings to be clan "C"o better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In. ,
spection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may In any way accrue against said City in consequence
of the granting of this permit. SIGNATURE OF APPLI T 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
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