R 4970 PERMIT R_ 497
0
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 ADDRESS
S0RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
/� YES ❑ yes—I understand that a Gass A
NAME ".� of assemby is required.
,�
NO Initial LO,B.O.k
ADDRESS
PHONE b� NUMBER OF EXISTING COVERINGS
CONTR TOR'S /^
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS f TYPE OF ROOF COVERING
CIN&ZIP
• EXISTING
PHONE BUILT-UP ROOF ❑
NUMBER ASPHALT SHINGLES
ENSED ONTRACTORS DECLARATION
I hereby affirm that I em licensed under provislons of Chapter B(commencing with Section WOOD SHAKES El7000)of Division 3 of the Business end Professions Code,end my license le In full force and
WOOD SHINGLES
Cleanse Claes LI Number '
Date Ca actor OTHER(SPECIFY),, 4 ❑
OWNER-B DER DECLARATION PROPOSED 400 0(>
I hereby affirm that I am exempt from the ntreclor'e License Lew for the following reason,.
(Sec.7031.5,Business and Professions Cod Any city or county which requires a permit to (%n yy
construct.alter,improve,demolish,or repair a ructure,prior to Its Issuance,also requires the BUILT-UP ROOF
e, I�Q ❑
applicant for such permit to file a signed stele n at' Is licensed pursuant to the provisions L• vvs
• of the Contractor's License Law(Chapter B(co ,Is 11 g with Section 7000)of Division 3 of the Utica
Business and Professions Code)o het he Ja xem in refrom and the basis for the alleged ASPHALT SHINGLES'/?//
exemption.Any violation of Section 7 Is W spyy i t for a permit subleMs,the applicant to hu
a civil penalty of not marathon five h dre II r $5 ):
❑I,asownor of the pro erty,.W�y withwa see their sole compensation,will do WOOD SHAKES - ❑
the work,end the etr a Is of 1 or a Bred for as a(Sec.7044,Business and Pmfes-
slonsCode:The Cctr to e a doesnot apply toanowner ofproperty who builds or WOOD SHINGLES
Improves lhereonp vi'a as yvoik himself or through ms own employees,provided that ❑
such imp rovemeil�pr no ntl C or offered for sale.If,however,the building or Improvement
Is sold wit In no year o m letIon,the awner-builder will have the burden of proving that he did OTHERSPECIFY
not build ar ImprovIN p ose of sale.). OTHER(SPECIFY) ❑
❑I,as owner of Me,prop ry,em exclusively contracting with licensed contractors to construct
the project(Sec.7044,Busln a and Professions Code:The Contractor's License Lew doe$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 contmctoq$)licensed pursuant to the Contractors License Lew. PROVIDE MFG R.INSTALLATION SPECS.
C]I am exempt under Sec. ,B&P.C.for this reason
Owner oats
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and S maintain 7 a Certificate of Consent to Performa for Worker's Compensation, Blllldln
as provided for by Section 3700 of the Labor Cotle,for the performance of the work for which this � ^ g
permit Is I6eua Seism!
❑I have d will maintain Worker's Compensation Insurance,es required by Section 3700 of nv
the Lebo ode,for the performance of the work for which this permit Is Issued.My Worker's
Comp tion Insurance carrier and Policy number are: TDtal
alar Policy No. PERMIJ AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed If the permit Is for one hundred dollars($100)or less.) ,
I certify that In the performance of the work for which this permit Is Issued,I shall not employ
any person In any manner so as to become subject to the Workers'Cion Laws of Cell. All roots shall i spect for to any ro fi teri e g
foals' installed. If a roof is inst
i� alled without rat obtain) an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and WIII comply with II non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP p y a p
with such provisions or this permit shell be deemed revoked. Source regulations.
I certify that I have reed this application and stet,that the above Information is correct.I agree
to hereby authorize
all city and County ordinances and ter u on the
above-mentioned
bov -mental needproperty
and All roof CMoretter.S 10 be C18S
hereby authorize city and County
al this city to enter upon the�ing to building
entlon construction.papally for im
spection purposes.
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may In any way accrue against said CIry In Consequence
of the granting of this permit.
SIGNATURE OF APPLICANT Of
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE INSP. DATE INSP. DATE
\J NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPV