R 49730
0
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBERR_ 4973
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
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RESIDENTIAL COMMERCIAL OTHER
OWNER'S- -�
HAZARDOUS FIRE AREA
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YES [:1 Ifyes — I understand that a Class A
NAME \ l
root assembly is required.
NO E] Initial I.C.B.O. q
EXISTING ROOF COVERING
ADDRESS -
PHONE
NUMBER OF EXISTING COVERINGS
CONTRACT O 'S
NAME
7O BE REMOVED l ` TO BE RETAINED
TYPE OF ROOF COVERING
CITY & ZI
CITU 8 ZIP
q
PHONE �- _ (
BUILT-UP ROOF
LICENSE
NUMBER
ASPHALT SHINGLES ❑
LIC- ED C01TRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 8 (commencing with Section
WOOD SHAKES
7000) of Division 3 of the Business and Professions Code, and my license is In full force and
effect.
Licena ea Lic. Number
WOOD SHINGLES ❑
14d. Q1
OTHER (SPECIFY) ❑
Dale Contractor
NER-BUILDERD ATI N
I hereby Irm that I am exempt from the Contractor's License Lew for the following reason.
PROPOSED
(Seo. 7031.5, Business and Professions Code: Any city or county which requires a permit 10
construct, alter,Improve,demolish, or repair any structure, prior to Its Issuance, also 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's License Lew (Chapter B (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 ❑
exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a dull penalty of not more than five hundred dollars ($500).):
1-] 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.
slons Code: The Contractor's License Lew does not apply to an owner of property who builds or
Improves does
WOOD SHINGLES ❑
thereon, and who 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
Is sold within one year of completion, the ownenbulider 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 Contractors License Lew 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 Contractor's License Law,
C]I am exempt untler Sec. ,B 6 P. C. for this reason
PROVIDE MFG R. INSTALLATION SPECS.
Owner Dare
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION
PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑ 1 have and wlll maintain a Certificate of Consent to self -insure for Worker's Compensation,
Building 6n Cb
as mit is is for by Section 3700 0l the Labor Code, for the performance of the work for which this
permit is issued.
Compensationrents, ea requlratl by Section 3700 of
❑ have end will maifimance
r
Seismic
the Labor de for thech ihla permit le leauetl. My Workers
Comp earl
Total /
11 L� ��
PERMIT AUTHORIZATION
DATE
Denner ucy6
CERTIFICATE OF EXEMPTION FROM WORKERS'
,
COMPENSATION INSURANCE
(This section need not be completed If the permit Is for one hundred dollen ($100)100) or lase.)
I certify that In the performance of the work for which this permit Is Issued, I shall not employ
All roofs shall be d prior to any roofing material being
any person In an manner so as to become subject to the Workers' Compens ll Laws of can-
,any
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installed. If a roof is installed without first obtaining an
DataApplicant
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you shout stoma
subject to the Workers' Compensation provisions of the Labor Code, you moat forlhwli comply
pp p y point
Applicant understands and will comply with all non
with such provisions or this permit sheP,be doomed 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 r coverings to be s"C"or better.
hereby authorize representatives of this city to enter upon the above-meniloned property for In-
spection purposes.
(We) agree to save, Indemnify and keep harmless the City of Cupertino against Ilabllltlea,
Jk
judgments, costa and expenses which may In any way accrue against said City In consequence
of the granting of this permit.
SIGNATURE OF 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
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