R 5856 r
PERMIT R_ 5856.
APPLICATION FOR CITY OF CUPERTINO NUMBER
R-
PERMIT INSPECTION DIVISION PERMIT EXPIRATION _J
(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 1 /I I' L ,
Io Z-20v I C. 1[..-S W RESIDENTIAL � COMMERCIAL OTHER
OWNERS^ HAZARDOUS FIRE AREA
( �1 YES ❑ iroof assembly strequirred.Clots A
NAME
NO ❑ Initil LC.B.O.ri
ADDRESS Z �n EXISTING ROOF COVERING
PHONE
a, 3 _ NUMBER OF EXISTING COVERINGS
CONTRACTOR' r
NAME 'J TO BE REMOVED TO BE RETAINED
ADDRESS jTYPE OF ROOF COVERING
(T r �O '
CITY&ZIP Off•
EXISTING
PHONE BUILT-UP ROOFLICENSE
NUMBER 'NTLZ ASPHALT SHINGLE4S
❑
LICENS D CORACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section 7 WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is in full force and
ones. D SHINGLES ❑
License Clara Lic.Number �'
Dale Contractor
OTHER(SPECIFY) ❑
OWNER.BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sea 7031.5,Business and Professions Code: Any city or county which requires a permit to
ccnetruct,eller,Improve.demolleh,or repair any structure.prior to its lesuance,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 Lew(Chapter S(commencingg with Section 7000)of DJvlslcn 3 of the
Business and Professions Code)or that he Is exempt therehom and the basis for the alleged ASPHALT SHINGLES O M
P p
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500).):
C]I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,andthe structure Is not Intended or offered for sale(Sec.7044,Business and Prof0s. ��� '1 p rD
Bions 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 awn employees.provided that O
WOOD SHINGLES d
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(SPECIFYfITY Uh LUrcoi IIVU
not build or Improve for purpose of sale.).
❑I,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 contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B&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 self-insure for Worker's Compensation, BUIIdinm
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit Is Issued. / Seismic
❑I havvand e entl will maintain Worker's Companeetlon Insurance,ae requlratl by Section 3700 of _k
the Labor Code,for the performance of the work for which this permit is Issued.My Worker's
Comp8,non Insurance car end Policy number ere: Total
Carrier PoIIcyNouL�—� a14f PERMIT AUTHORIZATION DATE
CERTIFICA F EXEMPTION FROM WORKERS'
CO NSATION INSURANCE N.C.O(Thiion need not be Completed If the permit Is for one hundred dollars($100)of lose.)
I certify that In the performance of the work for which this permit Is Issued,I shell not am Joy
any person In any manner so as to become subject to the Workers'Com neadon Laws of Call. All roofs shall be i spected prior to any roofing material being
fornix. installed. If a roof is installed without first obtaining an
Data� ./��'' App11 e„ c `,�L_, inspection,I agree to remove all new materials for inspection.
subject to thebWorkkeras'Compensation provisions of thelcato of Laborr Code,Exemption,
oiu must forthwliitth 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 reed 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 cove Ings to be class°C°Or better.
hereby authodae 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, f
jutlpmeno vests end expenses which may In any way accrue against said City".consequence
of ins 2mndnp orthia p mut. SIGN RE 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