R 5116 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 5116
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INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
my oon 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS U7 �' I RESIDENTIAL ,/lx"` COMMERCIAL OTHER
OVAERS HAZARDOUS FIRE AREA
/�0 VES [:j If yes—I understand that a Class A
NAME ( 6A.!l IL-��'1✓` roof assembly is required.
NO Initial_ I.C.B.O.IF
ADDRESS— 2U QJe�� EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS owe
CONTRAC R^'S
NAME
1 TO BE REMOVED TO BE RETAINED
ADDRESSn // 0TYPE OF ROOF COV
CITY&ZIP/Y2, ll✓Cbc� 7r lib O
_ EXISTING
PHONE 2 ( �� BUILT-UP ROOF
LICENSE
NUMBER r-171019 ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and
ansa. /U/q WOOD SHINGLES ElUcenee CI a Lie.Number /
Oats Contractor
OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby,en rm 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
applicant for such permit to file a signed statement that he to licensed pursuant to the provisions
of the Contractor's License Law(Chapter 9(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 permit subjects the applicant to
e civil penalty of not more than five hundred dollars($500).): WOOD SHAKES
❑I,as owner of the property,or my employees with wages as their sole compensation,will do ❑
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Proles.
alone Code:The Contractor's License Lew 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.It,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 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 contractoda)licensed pursuant to the Contractors License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑1 em exempt under Sec. ,B&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:
B l have and will maintain a Certificate of Consent to Sell-insure for Workers Compensation, (�L�/] Building
as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which this v4Y' 1
permit Is Issued. o
. hon,ve and will maintain Worker's Compensation Insurance,as required by Section 3700 of ' r� v SBISRIIC
i Labor Code,for the performance of the work for which this permit Ia Issued,My Workers F
Compensaat'lry/_�Inq�rence carrl�ntl Pa y number are: � )1 �`•r .�,,F I fl �1✓(✓ Total
carrier STi_ C• Policy No./ 6
{_(QlL _`�� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.I]
(This section need not be completed If the permit Is for one hundred dollars($100)or lees.)
I certify that In the performance of the work for which this permit Is Issued,I$hall not employ
any person In any manner so as to became 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
Data Applicant inspection,I agree to remove all new materials for inspection.
NOTICsubject to the Workers'CompeTO APPLICANT: f,after nsation provisions at the Labor Code,s Certificate of Exemption,
mustuforthwllhbecome complyi2!JUHaVVA1TLE1CANT
n 'I comply with all non point
with such provisions or this permit shall be deemed revoked,
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,endla �C"Or er. ^
hereby authorize representatives of this city to enter upon the above-mentioned property icer IIt /(yL
spectlon purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino a alnst liabilities,
judgments,costs and expenses which may In any way accrue against said Clty�n consequence
• of the granting of this permit. NT
PRE-INSPECTION: PLYWOOD: 1 •PROGRESS:
INSP.—DATE INSP. DATE INSP.—DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP.—DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
n FFIr.F rnIxV