R 5218 (2) PERMIT R_ 5 218 .
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
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
r
NAME • YES ❑ 11 as—I undersand roof assembtysirequiired.at aCssaA
NO ❑ Initial I.C.B.O.#
ADDRESS _s EXISTING ROOF COVERING
PHONE d 0 25 -.1-4 NUMBER OF EXISTING COVERINGS I
CONTRACT . �
` TO BE REMOVED TO BE RETAINED
NAME 414,
ADDRESS `p n'raJ '1� V TYPE OF ROOF COVERING
CITY&ZIP , lL h(Ir/K_ -bt/
PHONE�dO— 6 ^ 7 �yU BUILT-UP ROOF ❑
LICENSE / ❑ ����
NUMBER (O8 � ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter a(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license is In full force and
affect. /� / ❑ So
License Claes Lic.Number � v WOOD SHINGLES
Date Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATIOI( PROPOSED P � Q
ID
I hereby affirm that I em exempt from the Contractor's License Law for the following reason.
(Sec.703 .6,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 Irl u121996
applicant for such permit to Elle a signed statement that he is licensed pursuant to the provisions asr�
of the Contractors License Lew(Chapter B(wmmencing 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 LSI t�
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to CITWUF CUPEHIINO
a civil penalty of not more than five hundred dollars($500).1:
E]1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure le not Intended or offered for sole(Sec.7044,Business and Proles-
slonsCode:The Contractors 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.).
❑1,as owner of the properly,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. ✓O 3 7
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.
E]I am exempt under Sec. ,B a P.C,for this reason
Owner Data APPLICATION DATE VALUATI PERMIT FEE
WORKER'S COMPENSATION DECLARATION
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`
d as provided for by Section 3700 of the Labor Code,for the performance of the work for which this / O
pe`rm�'-ia leeuad. p
}L bor Code,
will maintain Workers t the work
for Insurance,this pe required by SectionWorks a1 Seismic �
Ih Labor Code,for the performance of the work for which this permit is Issued.My Workers / Q
Compensation Insure a carrier and Policy nu er are: Total
Carrier `. Policy No. 0VC. 30g40?-off PERMITAUT RIZATION DATE
CERTIFI ATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N C.❑
(This section need not be completed if the permit Is for one hundred dollars($100)or less.)
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 Laws of Dail- All roots B be inspected prior to any roofing material being
forms. installe . If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
subject to Eh Workers'CompeTO APPLICANT, nsation proviafter siones Certificate of s of the Labor Code,Exemption,
must forthwith become
comply Applicant understands and will comply with all non paint
with such provisions or this permit shall be deemed revoked. Source regulations.
I certify that I have reed this application and stele 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 cov ren be Cl SS°C"Or better.
hereby authorize representatives of this airy to enter upon me above-mentioned property for In.
'Nv-�^.✓
hereby
purposes. (`
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
ludpMonte,coats and expenses which may In any way accrue against said City In consequence
of hegremmgoftmaPermu. SIGNATUR&OFAPPLICANT 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
OFFICE COPY