R 5067Ll
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PERMIT
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APPLICATION FOR CITY of CUPERTiNO NUMBER 5067
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.
BUILDINGADDRESS
A A (0tC
RESIDENTIA COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
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YES ❑ If yes - I understand that a Class A
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roof assembly is required.
NO Initial (,C -� I.C.B.O. #
'
EXISTING ROOF COVERING
ADDRESS
PHONE -
NUMBER OF EXISTING COVERINGS
TO BE REMOVED TO BE RETAINED
CONT
NAAMERACTOR;$ /� ��� ����M -
ADDRSS
3 7 I - L M� J Lv Cs r-pbe �) L-9
TYPE OF ROOF COVERING
TY &EZIP t eek ,
EXISTING
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PHONE Sti —333y
BUILT-UP ROOF ❑
LICENSE-
2 6
NUMBER 1
ASPHALT SHING ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am Ilcenaetl under provisions of Chapter 8 (commencing with Section
WOOD SHAKE
7000) of Division 3 of the Business and Professions Code, and my license 1. In full force and
effect.
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49 5/76l
WOOD SHINGLES El
License Class J.. �C9 Lic. Number
OTHER (SPECIFY) ❑
g^/2 9 G -)M R.-
ale Contractor L f6i n
OWNER -BUILDER DECLARATION—
PROPOSED
I hereby affirm that I am 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, else requires the
BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor'° License Law (Chapter B (commencing with Section 7000) of Division 3 o1 the
Business and Professions Code) or that he Is exempt therefrom and the basis for the alleged
ASPHALT SHINGLES IDexemption.
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 do liars ($500).):
❑I, 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 (Sac. 7044, Business and Profes.
sIon° Code: The Contractors License Law does not apply to an owner of property who builds or
Improvea thereon,
WOOD SHINGLES ❑
and whodoes such work himself or through his own employees, provided that
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such Improvements are not Intended or offered for sale. If, 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
me project (Sac, 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 Improve° thereon, and who contracts for such projects
with a contractor(s) licensed pursuant to the Contractor's License Law.
I am exempt under Sec. ,B & P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner Date
WORKER'S COMPENSATION DECLARATION
O
APPLICATION DATE
VALUATION
ERMIT E
I hereby affirm under penalty of perjury one of the following declaration:
--NM have antl will maintain a Certificate of Consent to self -insure for Workers Compensation,
/aa'p cedforbySection3700oltheLaborCode,fortheperformanceoftheworkforwhichthis
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B no
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permit Is Issued.
^
I have and will maintain Workers Compensation Insurance, a° required by Section 3700 of
Labor Code, for the the for
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Seismic
performance of work which this permit is issued. My Workers
Compensation Insurance carrier and Policy number are:
Total
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OPt1F
Y.
• pERMITAUTHORIZATION
-
DATE
Carrier 19f/tr of Policy No.� �1L ���-BJ
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ
(This section need not be completed if the permit 1s for one hundred dollars ($100) or less.)
_
I certify that In the performance of the work for which this permit 13 Issued, I shall 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 Worker°' Compensatlon Laws of Cell.
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installed. If a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
Subject to theoWorrkers'C mpelnseion proafter visions Certificate orr Code, you musuminwimc mply
Applicant understands and will comply with all non point
with such provisions or this permit shalQbe 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.
All roof coverings to be class "C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spection purposes.
(We) agree to cave, Indemnity and keep harmless the City Of Cupertino against liabilities,
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jud menta, coat. and expenses which may In any way accrue against said City In consequence
IG RE OF APPLICANT DATE
of tgie granting of this permit.
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
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