R 5207 (2) 114 600
PERMIT R_ 52� 7
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 ADDRESSYO
� .
RESIDENTIAL COMMERCIAL OTHER
O NER'S w HAZARDOUS FIRE AREA
.{/f YES ❑ If yes—I understand that a Class A
NAM I _ —`� A/ roof assernbly is required.
Initial LC.B.O.ff
A —O��I ^� �(� EXISTING ROOF COVERING
PHONE O �/ r i �v NUMBER OF EXISTING COVERINGS
CONTRAC 'S
NAME TO BE REMOVED TO BE RETAINED
�
ADDRES /. , TYPE OF ROOF COVERING
CITY ZIP a�V EXISTING
PHO
PHO r ' o '3 BUILT-UP ROOF ❑
NUMBER D ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION \ -
I hereby affirm that I am licensed under provisions of Chapter g(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is in full force and
affect.
'-- gy WOOD SHINGLES ❑
License f Clese 1.� Llc.Number �j
Date! d^/5`-9,6 Contractor OTHER(SPECIFY) ❑ �/_
'R—BUILLDER CLARATION PROPOSED
I hereby affirm that I em exempt from the Contractor's 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 E]applicant for such permit to file a signed statement that he is licensed pursuant to the provisions
of the Contrecicrs License Law(Chapter B(commencing with Section 70001 of Division 3 0l the
• Business and Professions Coda)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
a civil penalty of not more than live hundred dollars($500).):
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES
the wark,and the structure Is not Intended or offered for sale(Sec.7044,Business and Proles.
alone Cotle:The Contractor's License Law does not apply to an owner of property who build$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 bullding 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,em 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(e)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner oma
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION FERMI E
hereby and under penalty of perjury e one of the fallowing declaration:
❑I have end will maintain 37 a Certs/scale of Consent to sell-Insure for Worker's Compensation, n
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this .410
permit is Issued. $61s IC
❑ have and will the pain Workers f the work
Insurance.as required IsI by Section Worker's
'sOar
s
the Labor Code,for the petlormand of the work for which lila permit la Issued.My Workers J L� 10,
�"I �r Total
Compensation Insurance carrier and Polley number are: '� 2 �/{� ^ gd 7
Carrier Policy No// ! f S 4�) UhPERMI THORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.[] fflV
(This section need not be completed if the permit Is for one hundred dollars($100)or less.) e/� ' r
v 1
I cartlty that In the pedormance of the work for which this permit Is Issued,I shall not employ
any person In any manner so as to become sub et to PeAuSkers'Compensation Laws of Call. All roofs,shall be inspected prior to any roofing material being
for"ia.N,_/� 'qj - j, t f(�_ --A—
D . installed. If a roof is installed without first obtaining an
dte /(e Applican lJ � O-0-r inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,alter making this Certificate of Exemption,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensation pprovision of the Labor Code,you must forthwith comply pP P Y P
with such provislone or life parmlt ehall+be 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 dna state Iowa relating to building construction,and All Of COVBfIn S t0 be class"C"Or better.
hereby authorize representatives of this airy to enter upon the above-mentioned property for In- / ^��
spectlon purposes. `
(We)agree to save,Indemnity and keep harmleea the City of Cupertino against Ilabllltles, v
judgments,costs and expenses which may in any way accrue against said City In consequence
• of this permit. G ATU DATE
PRE-INSPECTIONPLYWOOD: 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 ,