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OFFICE COPY
ERMIT R- 58 61
APPLICATION FOR CITY OF CUPERTINO NUMBER
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.
BUILDINGADDRESS •//
,C J
RESIDENTIAL COMMERCIAL - OTHER
owNER's
HAZARDOUS FIRE AREA
YES A
Class '
NAME
roof assembly is required. .
NO Initial I.C.B.O. q
" -
EXISTING ROOF COVERING
ADDRESS
PHONE
NUMBER OF EXISTING COVERINGS
CONTRACTO/JR'S
/
NAME ( C �/�� /�•-O ���/Y CY r
TO BE REMOVED TO BE RETAINED
ADDRESS
�YPF OF ROOF COVERING
CITY & ZIP
EXISTING
PHONE —�� /
BUILT -UP ROOF ❑
—ZIMS;,C
LICENSE
NUMBER 6 )k__ -
ASPHALT SHINGLES ❑
'
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter S (commencing with Section
WOOD SHAKES
7000) of Division 3 of the Business and Professions Code, and my license Is In lull force and
C
enact.
p
e _ i 6
WOOD SHINGLES ❑ �jL
License Class LIc. Number /
Date Contractor
OTHER (SPECIFY) ❑
OWNER- BUILDER DECLARATION
I hereby affirm that I em exempt from the Contractors License Law for the following reason.
PROPOSED
and Code: Any city or county which requires a permit to
(Sec. 7ct,
alt , Improve
demolish, or rep any structure, prior lo Its Issuance, also requires
conecant,orsuImprove,tlfilea
for
BUILT -UP ROOF ❑
applicant such permit to Ills a signed
signed that he Is licensed pursuant to the provisions
uant to the provisions
r 9 commencing
of the Business ancctors License Lew (Chapter a (commencing with Sactlon 7000) of Division 3 of the
Section
end Code) or that he Is exempt therefrom and the basic for the alleged
ASPHALT SHINGLES (�4
exemption violation of
exemption. Any violationofhan Section by any applicant for o permit subjects the applicant to
five hundred
e civil penalty of not more than live hundred tlallars ($500).):
C] 1, as owner of the property, or my employees with wages as their sole compensation, will do
WOOD SHAKES ❑
the work, and the structure is not intended or offered for sale (Sec. 7044, Business and Profes-
sionsCode: The Contractor's License Law does not apply to an owner of property who bulidsor
Improves thereon, and who does such work himself or through his own employees, provided that
WOOD SHINGLES Cl
such Improvements are not Intended or offered for sale. If, however, the building or improvement
Is sold within one year of completion, the owner•bullder will have the burden of proving that he did
SPECIFY
OTHER (SPECIFY) ❑
not build or Improve for purpose of sale.).
. [:11, ea owner of the property, em exclusively contracting with licensed contractors to construct
the project (Sec. 7044, Business and Professions Code: The Contractors 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 contractoge) $canoed pursuant to the Contractor's License Law.
❑ (am exempt untler Sec. ,B & P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner Date
' WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION
PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
p
s'4
E] I have and wIII maintain a Certificate of Consent to self-insure for Workers Compensation,
as provided for by Section 3700 of the Labor Code, for the performance of the work for which INS
permit s sued.
Building
❑ 1 have and will Worker's Compensation Insurance, as required by Section 3700 of
®
Seismic —0—ANC)
the performance
-the Labor Code, for the perormand of the work for which This permit Is leeuetl. My Workers
Compensation Insurance center entl Policy number ere:
C/- Y
�
Total
Carrier.1:2a'lZ FI/N /5' Policy Na %3� �73�- 9 %
v�
PER 1CAUT{ RIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
Co
COMPENSATION INSURANCE N.C.]
(TMs settle$ need not be completed If the perm 510
it Is for one hundred dollars (0) or IeeaJ
I certify that In the performance of the work for which this permit Is Issued, I'hall not employ
All roofs shall be inspected prior to any roofing material being
any person In any manner so as to become subject to the wad, ra' ompensation Laws of Can.
fornia.
Dare D �7,4 Appnca B— Fsln�
installed. If a roof is installed without first obtaining an
inspection, I agree to remove all new materials for inspection.
NOTI TO PPLICANT: If, after makln this Car cats of Exsy Lion, u should become
subject to the Workers' Compensation prov Iona of i0 Labor Code, you must forthwith comply
Applicant understands and will comply with all non point
with such provisions or this permit statics deemed revoked.
Source regulations.
I certify that l 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. and
All roof coverings to a lass better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
V}J
spection purposes. -
(We) agree to save, Inderrnty, and keep harmless the City of Cupertino against liabilities,
D 8
judgments, coats and expenses which may In any way accrue against said City In consequence
0 '/OATE
of t granting of this perms.
-'jITATYMY APPLICA
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
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