R-5550 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBERR_ 5 5 5 0
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 190 DAYS OF PERMIT ISSUANCE OR
BUILDING ADDRESS
180 DAYS FROM LAST CALLED INSPECTION.//// ✓ Do,
RESIDENTIAL COMMERCIAL OTHER
OWNER'S �/9� HAZARDOUS FIRE AREA
NAME DO' ` T YES ❑ If yes s mbly is
that. Class A
root assembly Is requlred.
/� ��/� j� NO ❑ Initial I.C.B.O.M
ADDRESSy`101`T��(�(�''`�` L � M EXISTING ROOF COVERING
PHONE l`�E 42000— O3 NUMBER OF EXISTING COVE GS /
CONTRACTOR'S ✓/
TO BE REMOVED TO BE RETAINED
NAME—
ADDRESS
AME—.ADDRESS TYPE OF ROOF COVERING
CITY&ZIP
EXISTING
PHONE BUILT-UP ROOF ❑
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
]000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect' WOOD SHINGLES ❑
License Class Dc.Number
Date Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED �G
I hereby affirm that I am exempt from ow
the Contractor's License Law for the following reason. 4
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to L
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 Contractors License Lew(Chapter 9(commencing with Section]000)of Division 3 of the
. Business and Professions Cade)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES
exam Uon.Any violation of Section]031.5 by any epplitant fore permit subjects the applicant to
e d eneuy of not more men five hundred dollars(55001.): WOOD SHAKES
es owner of the property,or my employees with wages es Ihelr sole compenaa and
will do ❑
t wo and the structure is not Intentlad or offered for sale(Sec.]044,Business end Profaa-
sionsCOCe:The Contractor's License Lew does not apply to en owner of property who builds ar WOOD SHINGLES ❑
Improves thereon,and who does such work himself or through his awn employees,provided that
such Improvements are not intended or offered for sale.If,however,me building or improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑ p A Q
41 not b or Improve far purpose of sale.).
I,es owner of the property,am exclusively contracting with licensed contractors to construct �t�—�—
I lett(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
pply o an owner of property who builds or improves thereon,and who contracts for such projects
with a contractor(s)Ii sed pars t to the Contractor's License Law. PROVIDE MFGR.INSTALLATIO EC$.
�I em exempt u r Sec. ,B 8 P.C.for this reason
t rrnII1NU
weer Data APPLICATION DATE VALUATION PERMIT FEE
WORKERS COMPENSATION DECLARATION
r I hereby affirm under penalty of perjury one of the following declaration: /y�^
❑I have and will maintain a Certificate of Consent to salt-insure for Worker's Compensation, BUIlding `
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this (�/][��
permit is Issued. bilb I / F O
❑ have and will the performance
Worker's Compensation Insurance,as required by Section 3700's Seismic
s the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's O
Compensation Insurance carrier and Policy number are: Total
Carder Policy No. ERMITAUTHORIZATION D T
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.Ds
(This section need not be completed if the permit Is for one hundred dollars(5100)or Iass I
I certify that in me performance of the work for which this permit is issued,1 shell not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Cell- All 0 is shall be inspected prior to any roofing atenal eing
fornia. In Iled. If a roof is installed without first obtaining an
X 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 will comply with all n00 point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP P Y P
with such provisions or this permit shall be deemed revoked. Source r COP
S.
I certify that I have reed this application and stale that the above Information Is correct.)agree b
to comply with all city and county ordinances and state laws relating to building construction,and All ro c vto be class or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes.
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities,
oftthe granting of this expenses which may In any way accrue against said City In consequence IG E APPLICA T 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
OFFICE COPY