R 5105 PERMIT R_ 510 5
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
• 100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
-HAZARDOUS FIRE AREA
YES ❑ If year—I Lntlerstand that a Class A
NAME roof assembly is requimd.
NO ❑ Initial I.C.B.O.N
ADDRESS EXISTING F 9OVERING
�2PHONE NUMBER OF EXISTING COVERINGS
CONTRAC.IORS
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS5� TYPE OF ROOF COVERING
CITY 8 ZIP
EXISTING
PHONE p BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
hereby affirm that i em 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 full force and
effect. U� WOOD SHINGLES El
Cle Lk.Number ` '
Date Contrebtor
OTHER(SPECIFY) ❑
WNER-BUILDER DECLARATION PROPOSED
hereby a Irm that em exempt from the Contractors License Lew for Iha bllowing res on.
(Sec.703 .5,Business end Professions Code: Any city or county which requires a permit to
construct,alter.Improve,demolish,or repair any structure,prior to Its issuerce.also requlro.the BUILT-UP ROOF
applicant for such permit to file a signed statement that he is licensed pursuant to the provlalone _ p ��
of the Contractor's License Lew(Chapter 9(commencing with Section 7000)of Division 3 of the S 1,
. 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
e civil penalty of not more than five hundred dollars($w(h.): i
.,.1
❑Irks owner sthctureI not
tendedmy employeeswithwages(See,their 7041,compensation,sandProfes-
sions
WOOD SHAKES
the work,and the ontracto le not InsenLatl or s not for sale(Sec.7044,Business end Protea-
Improv Improves
The Contractorsaw snotrthroughhiso owner
own
property who provibuildsded
or
at WOOD SHINGLES
Improves mmeon,and who does deco work edforf or.If,how his own employees,provided reel ❑
such Improvements are not intended or offered for Bale.K,however,the building of Improvement
Is not
tbuild or
prove for purpose
sale.).
Owner-bulrderwlll have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of ealaJ.
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(d)licensed pursuant to the Contractors License Law, PROVIDE MFGR.INSTALLATION$PEO$.
[II am exempt under Sec. ,B a P.C.Mr this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to sel4lnaure for Worker's Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this g /
permit is Issued.
'M3Mava and will maintain We kar'e Compan etlon Insurance,as required by Section 3700 of I Seismic 9a
s V
-the L r Oda,for the performance of thew rk for which this permit is issued.My Wo ere l /
Com at n I au nc carr and Policy nu bar am: I � s �,/ Total - 0
Carrier FROMW ` +, PERMIT AUTHORIZATION DATE
CERTIFICATE EN EXEMPTION FROM WORKERS'
a COMPENSATION INSURANCE N.C.❑
(This section need not be completed If the permit is for one hundred dollars($100)or less.)
I sanity that In the performance of the work for which this permit is Issued,I shall not employ
any person In any m nner so as to become subject to the Workers'Compensation Lam of Cell. All roof^shall be inspected prior to any rooting material being
lornl installed. If a roof is installed without first obtaining an
y
Data Applicant inspection,I agree to remove all new materials for inspection.
NOTICE A (CANT: Il,after making this Certificate of Exemption,yo hould become Applicant understands and will comply with all non point
subject to t e Workers'Compensation provisions of the Labor Code,you must rthwllh comply PP p y p
with such provisions or this permit shalpoe 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 Totaling to building construction,and All roof coverings to beSS"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In- I
spection purposes,
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
judgments,caste and expenses which may In any way accrue against said City In consequence
. of the granting or 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
OFFICE COPV