R 5143 PERMIT R_ 514 3
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
100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
I \X/i^/
—Z-1S(/p` L A-) RESIDENTIAL COMMERCIAL OTHER
OWNERHAZARDOUS FIRE AREA
"e YES If yes-I understand that a Cl 43NAME NO roof assembly is required.ial I.C.B.O.X�
ADDRESS Z� 8�2 EXISTING ROOF COVERING
PHONE 6141&
4Ig NUMBER OF EXISTING COVERINGS I
�1
CONTR�TOr R'S�
SCc-nn.FQ t Cil TO BE REMOVED TO BE RETAINED
NAME 'w"�
ADDRESS �� 1 Z ��_C � �'I.�- c5�I Z TYPE OF ROOF COVERING
CITY 8 ZIP 1 I
EXISTING
PHONE BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES' ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am Ilcansed under provisions of Chapter 8(oommencing wlih S WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,Bind my license le In lull for e
Affect. / Z L� OD SHINGLES ❑
License Cl e C�J� Llc.Num � "'�
'y7 y OTHER(SPECIFY) ❑
Date Contras
OWNER-BUILDER DECLARATION P D
I hereby affirm that I am exempt from the Contractor's License Lew for the bllowinp 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 �QILT-UP ROOF " ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provlaione
• of the Contractors License Law(Chaplar 8(commencing with Section 7000)of Divislon 3 of the
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLE-SEP 2 7
exemption.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),):
❑l,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES(.',f , IJP- ❑
the work,and the structure Is not intended or offered for sale(Sec.7044,Business and Profile. VU.-�� U
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.If,however,the building or Improvement �^1� 1�' A
is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER (SPECIFY) ❑ .bu"
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 contractor(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT
' WORKER'S COMPENSATION DECLARATION
hereby affirm under penalty of perjury one of the following sure for
Wo �S
have and will maintain a of the
of Consent to eperforma for Worker's Compensation, B,/,
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this �/
P
rattle lsauetl. "I7 Seismic
ave end will maintain Workers Compensation Insurance,as required by Section 3700 of
t or Code,for the performance of the work for which this permit is Issued.My Works"
ompe satlons�Insura'rnce carrier antl Iley number are: Total
Carrier`-"y �"` Policy No. Z8s3 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.] s�
(This section need not be completed If the permit is for one hundred dollars($100)or lase.) I�rj
I certify that In the performance of the work for which this permI la lsauetl,I shall not employ
any person In any manner so as to becomesubject to the W er Compeneatlon Lawa of Call. All roof^ all be inspected prior o any roofin mat ing
to me. installed. If a roof is installed without first obtaining an
Dala �' Appn inspection,I agree to remove all new materials for inspection.
NOTIC11 TO AP LICANT: If,after g this Certificate of Exemption,you should become Applicant understands and will cora
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP ply with all non point
with such provisions or this permit shalribe 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 Bring lass or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for Ira
spection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
judgmenta,costs and expenses which may In any way accrue against said City...coneequenca
• oltRagrantingofthispermit. SIGNATURE OF APPLICANT DAII
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
rOFFIrC rei