R 5799 PERMIT R_ 579
9
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILD�IN/G'ADDRESS
(-1lJ Uj_ RESIDENTIAL COMMERCIAL OTHER
OWNER'S /' HAZARDOUS FIRE AREA
IRAN + 4 I NOM Pso�I VES ❑ If yes—I understand that a Class A
NAME �[ N roof assembly is required.
( NO ❑ Initial I.C.B.O.N
ADDRESS—( ( ( / EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS '
CONTRACTOR'S /^—��
NAME
�A6U 6tz4 211 l—J—(U� TO BE REMOVED TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP
366- 2B`5 1 EXISTING
� PHONE BUILT-UP ROOF ❑
NUMBSE
EaASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION 11
I hereby affirm that I am licensed under provisions of Chapter e.(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect.
WOOD SHINGLES ❑
License Class LIc.Number
Dale Contractor
OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
1 hereby affirm that I am exempt from the Contractors License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to p
construct,altar,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF p�a�
applicant for such permit to file a signed statement that he le licensed pursuant to the provisions
of the Contractor's License Law(Chapter B(commencing with Section 7000)of Division 3 of the �fUYSr®
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 permit subjects the applicant to nrl g V
e civil penalty of not more than five hundred dollars(8500).): 1q`I�1
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES vJ
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profile- rl,lY Jf V OGn I I1
cions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES V ❑
Improves thereon,and who does such work himself or through his own employees,provided that
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 exclusive contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors 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 Contractors License Law, PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B&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:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Building /Z 7
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this S ^� g
permit is Issued. I—/yam Jam+ Seismic
❑I have and will the performance
Worker's Compensation the wokfor Insurance,as required by Section 3700 of
„the Lector Code,for the performance of the work for which this permit Is Issued.My Worker's Total �Z r ilo.
Compensation Insurance carrier and Policy.n�umber are: '
Carrier j0i C_ ,(/J — Policy No. 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 lees.)
I certify that In the performance of the work for which this permit Is Issued,I shall not emoIoy
any person In any manner so as to become subject to the Workers'Compensation Laws of Call- All roofs Shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
jtomTO CIf,after
making
11Exemption,YOU
shbecome
ould to e WorrkereCmpeneeton provisions of the Labor Codeou Must forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shalObe deemed revoked. source regulations.
I certify that I 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 All roof coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.spection purposes
(We)agree to save,Intlemnlfy and keep harmless the City of Cupertino against liabilities,.
of'he
gran,costa and expenses which may In any way accrue against said CITY in consequence
of the granting of this permit. 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