R 5104 PERMIT R_ 510 4
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 X
IQ�;� RESIDENTIAL" ` COMMERCIAL OTHER
O NERN( S HAZARDOUS FIRE AREA
V1 NLH'�tl-'M, VES ❑ If yes-]unde HAZARDOUS
ClassA
N assembly is required.
n NO Jf root Initial I.C.B.O.W
ADDREss s rte�>'—'�"� EXISTING ROOF COVERING
PHONE 3 NUMBER OF EXISTING COVERINGS
CONTRP,PTOIR'S
r TO BE REMOVED TO BE RETAINED
NAME
ADDRESS J1,11- TYPE OF ROOF COV
CITY&ZIP-
PHONE BUILT-UP ROOF ❑ e /
LICENSE
2y
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code.and my license Is In lull force and
anent. ^y WOOD SHINGLES ❑
License CIe—C',--Z> J.. Lic.Number ` r� -
oate� -BUILDER
OTHER(SPECIFY) SEP 1 Vim'
`t Ib �I�om the
DECLARATION PROPOSED V 7996
hereby affirm that m exempt from the Contractor's License Lew for the following mato. 1I f I -
(Sec.70315, ,Improve,
and Professions Code: Any city or county which e" also
requires a permit to r ff (,l,l
consUuct,alter,h prove,to file signedrepair statement that
prior Coits l pursuant to
sms BUILT-UP ROOF
applicant for such permit to file a signed statement that g it licensed pursuant to the provolone
of the ss an Contractor's License Lew(Chapter he Is ex(commencing t with Section 7000)of for the 3 of the
Business end violation of Coda)or 0311 he la exempt therefrom and the beefs for the scant to ASPHALT SHINGLES
exemption.Any violation more
of Section 7031.$by any applicant for a permit subjects the applicant to
e civil penalty of not mora roan flue hundred dollars($$00)J: �
❑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 Palos.
alone Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,provided that ❑
such Improvements are not Intended or offered for Sala.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
the project(Sec.7044,Business and Professions Code:The Contractor's License Law floes 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, PROVIDE MFGR.INSTALLATION SPECS.
E)I am exempt under Sec. ,B 8 P.C.for this reason
Owner DeAPPLICATION DATE VALUATION PERMIT FE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of per ury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, BUlldln
as provides for by Section 3700 0l the Labor Code,for me performance of the work for which this /�
permit
the La Isissued.
Code. ("•1\ ( 10 1/�f,/I,Ify $eISfT11C
❑1 have and will maintain Worker's Compensation Insurance.as resulted by Section 3700 of
the Labor Code,for the performance of the wor for which ihls ermll Is Issue a.My Workers
Comps Insure tattler d Policy num are: l I I Total
ca`3ar y I PERMIT AUTHORIZATION DATE
ERTIFICATE OF EXEMPTIO FROM WORKERS'
COMPENSATION INSURANCE N,C.❑ t
(This section need not be completed If the permit is for one hundred dollars($100)or lase.) o
I certif that In the performance of the work for which this permit Is Issued,1.hall not employ CA
any pars In any anner Boas to become a to the W (Airs'Co eneatIon Laws of call. All roofs Shall be inspected prior to an roofing at 1 being
for installed. If a roof is installed without first obtaining an
Date ppucannnt inspection,I agree to remove all new materials for inspection.
NOTIC T APP (CANT: If,after making hi.Ceruficat of Exemption,you Should become Applicant understands and will Comply with all non point
subject to
Works 'Compensation provisions of the Labor Cotle,you must forthwith comply PP p Y p
with such prdvlelone or this permit shell be deam,d 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 b ass"C' rbettBr.
hereby authorize representatives of this city to enter upon the above-mentloned property for In.
spection purposes. Lb(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 Sold City In coneeq -_
of the granting of this permit. 5IGNKTURF OF APIDUCANT D E
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