R 4971:0
0
OFFICE COPY
PERMIT R_ 4971
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.
BUILDINGADDRESS
O �C./ ' &7,ro
` ' T \ t
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
YES ❑ If yes - I understand that a Class A
NAME—
roof assembly is required.
NO ❑ Initial I.C.B.O. ri
1
r _
EXISTING ROOF
ADD E
fCOVERING
NUMBER OF EXISTING COVERINGS `
PH Ess " l/^� ` V
CON ACT 'S
NAME -
TO BE REMOVED � TO BE RETAINED
ADDRESS ''
TYPE OF ROOF COVERING
CITY821P
r EXISTING
((��
PHONE 1
BUILT-UP ROOF ❑
_
LICENSE
NUMBER
ASPHALT SHINGLES ❑ '
LICENSED CON RACTORS DECLARATION
hereby affirm that I am licensed under provisions of Chapter B (commencing with Section
700 0) of Dlylitgelt 3 of the Business and Professions Code, and my license is In full force and
effect.
WOOD SHAKES
WOOD SHINGLES ❑
License le Llc. Number
Atcontractor
OTHER (SPECIFY) ❑
Date
WfromBUILDERDEC N
PROPOSED
hereby efflrm that I exempt from the License Lew for the following res
e: Any
Code: Any city or county which requires e permit
t
(Sec. 70315, Business and Profedemolish,
alter, Improve, or rep
or repeat any structure, its laeuancs, also requires the
BUILT-UP ROOF ❑
fila a signed
applicant for such permit to (its signed that is liven
applicant D the prmof
o the License r 9 (co m 000) oto
Law (Chaplet (commencing with Section 7000) of Division 3 of me
g ith Sectio the
/
Business end
ss an Pr fssions Code) or that he Is exempt
h and the basis for the
ASPHALT SHINGLES ❑ �e
ex violation Of
exemption. Any violation of Section 70315 by any applicant for a permit subjects the applleenl to
antfora applicant to
a civil penalty of not more than live hundred dollars ($500).):
WOOD SHAKES
❑I,as owner of the property, or my employees with wages as their sole compensation, will do
the work, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Press.
Sierra Code: The Contractor's License Law does not apply to an owner of property who builds or
Improves thereon, does
WOOD SHINGLES ❑
and who such work himself or through his own employees, provided that
such improvements are not Intended or offered for sale. If, however, the bulking or Improvement
Is sold within one year of completion, the owner -bulkier 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 (See. 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 contractors) licensed pursuant to the Contractor's License Law.
PROVIDE MFGR. INSTALLATION SPECS.
C]i am exempt under Sac. ,B 8 P. C. for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION
PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑ I have and will maintain a Certificate of Consent to self -insure for Worker's Compensation,
as for by Section 3700 of the Labor Code, for the the for
/'� 7L
( /1
Building -�--�—
provided performance of work which this
permitisIssued.
❑ I have and will maintain Workers compensation Insurance, by Section
.) I 1
�}U� 1v` (q
' �7 -
Seismic i 1�Q
as required 3700 of
-the Labor Coda, for the performance of the work r which this pe mit is Issued. My Workers
Compere n ranee c rd entl Icy numbs era: 4-
%
Total
Carder Policy No.
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed It 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 inspected pri o any roofing material being
person n any manner so as to become su soil to the Works ' Comps anon Lawn m can-
tory
installed. If a roof is insta ed without first obtaining an
Dat �' pplicant
inspection, I agree to remove all new materials for inspection.
subject to Igor rs, Compensation proviLICA ; If, after sions oftheLabor Code, cate you must forthwid become
th comply
Applicant understands and will comply with all non point
with such provisions or this permit shal¢be deemed revoked,
source regulations.
I certify that 1 have read this application and stale 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 cl "C" or better.
hereby authorize representatives of this city to enter upon the above-mentioned proparry for In.
/
spection purposes.
(We) agree to save, indemnity and keep harmless the City of Cupertino against liabilities,
1/Ur
judgments, costa and expenses which may In any way accrue against said Cityin consequence
SIGNATURE OF APPLIC
T D E
of the 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
OFFICE COPY