R 5199 PERMIT R_ 5199
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
• 100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
Z Z RESIDENTIAI/Z COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES 0 NAME X� C_ roof assembersstrequired. ClassA
ty required.
NO Inilial LC.B.O.g
ADDRESS EXISTING ROOF COVERING
PHONE
NUMBER OF EXISTING COVERINGS v
CONTRACTO /7
1�/—"-O� OBE REMOVED TO BE RETAINED
NAME
e ADDRESS TYPE OF ROOF COVERING
CITY&ZIP
x / EXISTING
PHONE W4 �[n `6/LL BUILT-UP ROOF ❑
LICENSE 1 �
NUMBER L..J ASPHALTSHINGLES ❑
LIC NSED CONTRACTORS DECLARATION /
I hereby affirm that I em licensed under provisions of Chapter B(commencing with Section WOOD SHAKES LmT/
7000)of Division 3 of the Business and Professions Code,and my license Is in full force and
effect. WOOD SHINGLES oa/t/aI
License Claes INumber El
Date Contractor
OTHER(SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED
I 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
construct,alter,Improve,demolish,or repair any structure,prior to its Issuance,also requires the BUILT-UP ROOF CCp �p ��CfD
applicant for such permit to file a signed statement that he to licensed pursuant to the provisions SEP of the Contractors License Law(Chapter g(commenclnp with Section 7000)of Division 3 of the
• Business and Professions Code)or that he Is exempt Iharelrom 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 rllr L/, Vt,i-„��i❑\/V
e civil penalty of not more than live hundred dollars($500).): ST
01,as owner of the property,or my employees with wages as their sole compensatlon,will do WOOD SHAKES
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profile.
.Ions 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 ❑
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 exclusively contraclln g,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 III INSTALLATION SPECS.
❑1 am exempt under Sec. ,S 6 P.C.for this reason
Owner Data
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
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is Issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of Seismic
the labor Code.for the Porto mance of the work for which this permit Is issued.My Workers
Compene neur ce c antl Pollcy number are: Total
Carrier Policy No. W PERMIT AUTHORIZATION DATE
' CERTIFICATEEXEMPTION FROM WORKERS'
COMPE!SATION INSURANCE N.C.D opO /S
(This section need not be completed If the permit is for one hundred dollars($100)or lase.) 1IV—
I certify that In the performance of the work for which this permit Is Issued,I shall not am toy
any person In any manner so as to become subject to the Workers'Compensation Laws of Colh All roof^shall be inspected prior to any roofing material being
fornla. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICsubject toETO APPLICANT:the Workers'Compef,shotnsation roOakinslonls of theyomust should
Certificate
Code,Exemption,
youullticcomply Applicant understands and will comply with all non point
with such provisions or this permit ehal�jbe 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” "Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spectlon purposes.
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities,
judgments,costa antl expenses which may in any way accrue against said City In consequence
•
oft
f the granting of this Permit. SIGNAT 14 P NT DAT
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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