R-5704 APPLICATION FOR CITY OF CUPERTINO
NUMBER PERMIT
R- 5704
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.
BUILDING ADDRESS
'O Z / d--Jg�ffnA RESIDENTIALCOMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
\A YES C] If yes—I understand that a Class A
NAME—\D- QtJ' d �n�\l� 1fn roof assembly is required.
NO'NP Initial I.C.B.O.If
ADDRESS
Sp 11"o EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
� � �1r� • TO BE REMOVED TO BE RETAINED
NAME
ADDRESSTYPE OF ROOF COVERING
CITY a ZIP
7 x EXISTING
PHONE74 4 qJQ) BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES ❑ !�
LI ED CONTRACTORS DECIARATION
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 full force and ` ��
elle`` ^ WOOD SHINGLES �
License Class _((jj Lia Number ` �' s(^
Date �/ ^1"�•IContractor M OTHER (SPECIFY) ❑ ///���
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sac.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 lila a signed statement that he is licensed pursuant to the provisions
of the Contractors 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
exempiton.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)): WOOD SHAKES
I]I,as owner of the property,or my employees with wages as their sole compensation,will do Elthe work,and the structure is not Intended or offered for sale(Sec.7044,Business and Poles-
alone Code:The Contractor's 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.II,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 Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who bullds or improves thereon,and who contracts for such projects
with a contractods)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
I am exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION q
I hereby affirm under penalty of parjury one of the following declaration: P A 1 D
❑1 have and will maintain a Certificate of Consent to self-insure for Workers Compensation, B W Iden
as provided for by Section 3700 of the Labor Cotle,for the performance of the work for which this
permit is issued.
I have and will maintain Worker's Compensation Insurance,as requ l red by Section 3700 of D�r^ m Seismic
the Labor Code,for the performance of the work for which this permit is issued.My Workers `LC
Comes sa onln urancecar' ndPolicy number are: 9 Ra �O Total
Carrle'r NA'4 � Policy No.�� 1 I'KAlph'ifpRIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' 1
COMPENSATION INSURANCE (N.C. /y Cn
(This section need not be completed if the permit is ne hundred dollars($100)or lass.) Y1
I certify that In the performance of the work for wn 1 is p Is sue all not employ
any person in any manner so as to become subjec m w era' enaa tan Lawe of c li All roots shall be inspected prior to any roofing material being
for" —/�1 installed. If a roof is installed without first obtaining an
Date _ Applice inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after ski this rlilic of Exa pilon,y should become q Iicant Und stands and will comply with all non point
subject m[he Workers'Compensation'park'161 the bor Code,you must forthwith comply PP P y
with such provisions or this permit shall b da d r ketl. SOUfCe regUl If
certify(hall have reatl thio epplicalion stale that the above information is corred.l agree
to comply with all city and county ordinances and stale laws relating to building construction,and All roof CO r I ec "C"o better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in- Y-'
spectlon purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities, J
judgments,costs and expenses which may in any way accrue against said City In consequence
of the granting of this permit. A R F 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
__ _ OFFICE COPY