R 5078 PERMIT R_ 5078
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 160 DAYS OF PERMIT ISSUANCE OR
• 160 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNERS HAZARDOUS FIRE AREA
YES ❑ If yes-I understand that a Class A
NAME roof assembly is required.
Initial LC.B.O.M
ADDRESS . EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR' // Q TO BE REMOVED_Z_TO BE RETAINED
NAME r/ �i•
ADDRESS 'f .� TYPE OF ROOF COVERING
CITU 8 ZIP /`
PHONE ` D BUILT-UP RO ❑
LICENSE
NUMBER ASPHALT SHINGL ❑
LICENSED CONTRACTORS DECLARATION
hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES ❑
]000)of Division 3 of the Business and Professions Code.and my license Is In lull force and
effect.
WOOD SHINGLES�g
License Claes Lic.Number /
Date Contractor
OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED !Fe
hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any clry 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 Elapplicant for such permit to ilia a signed statement that he is licensed pursuant to the provisions
of the• Contractor's License Law(Chapter S(commencing with Section 70001 of Division 3 of the n 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
a civil penalty of not more than five hundred dollars($500).):
❑e,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 Press.
seine Code:The Contractor's License Law does noteppryto an ghhisownerOwn eof mployees.
who builds WOOD SHINGLES2cZ 19Fl.
Improves othereon,meis are
who doessuchor work offered
or .11,however,
a own employee6,Improvement
provided AUGW N 2 56
such Improvements ara not Completion.
or offered for leer.d,have the the en Of Pr or Improvement
is sold within one year at completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of ease.).
I,as owner of the roe MI Y (�I' (yU}'�-i11IkV
apthe ply to
7044,Business who
tlsofr Improv Cotle:Theon,and who for
Lew does not PROVIDE LC.B.O.REPORT NO.
apply tc ntowner of property who pursuant
or Improves merlon end who contracts for such projects
with a e m exempt licensed pureupnt to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B 8 P.C.for this reason
Owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: tea/ e1
,S
❑Ihave and will maintain a of the
abof Consent toeperforure for Worker's Compensation,which
/' 1' Building / / /
as mit Is Issued.d for by section 3700 al the Labor Cotle,for the performance al the work for which Ihle
Oermlt la vSeismic /- �—
❑ have and will the performance
Workrman ee f the work
for Insurance,as required by section 370001
the Labor Coda,for the performance of the work for which this permit Is laeuetl.My Workers / �--
Compensation Insurance carrier and Policy number are: ql�
Total
Carrier Policy No. P MIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed it the permit is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this permit I ued,I shall not empoy
any pemo any man a as to become subject t e rke pansatlon Laws of Call• All roofs shall be inSpe ted prior to any roof g m terial being
torose. installed. If a roof is installed without first obtainingan
e Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: 11,atter making this Certlllce m
f Exeption,you should become
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. source regulations.
I certify that I have read this eordin ordinances
state that the above information lencorrect,oagree V"V
to comply byathor all city and county of this cel and state laws relating e-mention construction.f,an tl All r0 Ycoveringbe class"C"or better.
hereby authorize representatives al this city to enter upon the above-mentioned property for In.
epection(We) purposes.
(We)_area to save,indemnity and keep harmless the City of Cupertino against liabilities,
judgments,coats and expenses which may In any way accrue against said City In consequence a
of the granting of this permit. GNA UR 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 COPY