R 510117
4
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OFFICE COPY
PERMIT R_ 5101
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
RESIDENTIAL
RESIDENTIAL' -f COMMERCIAL OTHER
OVINE 's
HAZARDOUS FIRE AREA
YES ❑ If yes - I understand that a Class A
NAME
roof assembly is required.
NO ❑ Initial I.C.B.O. N
ADDRESS
EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS
I
PH 0 2
CONTRACTOR'S
y
NA
TO BE REMOVED TO BE RETAINED
ADDRESS
TYPE OF ROOF COVERING
CITY & ZIP -
EXISTING
PHONE
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BUILT-UP ROOFLICENSE �c
NUMBER
ASPHALTSHINGLES
'
E D CONTRACTORS DECLAflATION
I hereby affirm that I am licensed under provisions of Chapter a (commencing with Section
7000) of Division 3 of the Business and Professions Cotle, and my license Is In full force and
WOOD SHAKES ❑
ellsct.
Lie. Number
WOOD SHINGLES EDLicense
OTHER (SPECIFY)
oatA Contractor i A
OWNER -BUILDER TIO
here y affirm t et am exempt from the Contr what's License Lew for the following r so .
PROPOSED L
(Bee. 703 ,5, Bust as and Profeesons Code: Any city or county which requires a permit to
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 Contractor's License Law (Chapter g (commencing with Section 7000) of Division 3 of the
[7 O�
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 hire permit subjects the applicant to
five
- r j Lr 96
a civil penalty of not more than hundred dollars ($500).):
❑I, as owner of the property. or my employees with wages as their sole compensation, will do
WOOD SHAKES4.J
Ori
the work, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Profes.
vtJ
cions Code: The Contractor's License Law done 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 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 bulld or Improve for purpose of salts),
❑ I, as owner of the property, am exclusive contracting with licensed contractors to construct
the project (Sec. 7044, Business and Professions Code: The Contractor's License Law dose 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.
[II am exempt under Sec. ,B a P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner Data
WORKER'S COMPENSATION DECLARATION
APPLICATION DATEI
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,
BUlldm
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
permit Is Issued.
Worker's Compensation Insurance, by Section
❑ I have and will maithe
/'�
Seismic
3700 s
as required Is I
performance the wankfor
,the Labor Cotle, for the performance of the coot for which iMa permit le Issued. My Worker'a
J
71 U
Com an He Insure ce carrlef �'0tiny numb r are:
Total
Car r— t- Policy Ne. (] /
PERMIT AUTHORI
DATE
In
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ
(Thio section need not be completed It the permit Is for one hundred dollars ($100) or lase.)
I certify that In the performance of the work for which this permit Is issued, I shall not employ
All roof.^. shall be pecte prior to any roofing terial being
any person in any nionner so as to become subject to the Workers' Compone n Lewa o/ Calb
-
forni
installed. If a roof is installed without first obtaining an
Date ApplicantCA�
inspection, I agree to remove all new materials for inspection.
N TO APP CANT: It, after making this Certificate of Exemption, you she Deco e 1
subject to a Worke ' Compensation provisions of the Labor Code, you must forthwl eom ly
Applicant understands and will comply with all non point
with such provisions r this permit shal@bs 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 clty and county ordinances and state laws relating to building construction, and
All roof coverings to b class "C" 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 agalnst liabilities,
judgments. costa and expenses which may In any way accrue against said City In consequence
SIG ATU E OF 4 qATE
of me 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY