R 5060 PERMIT R_ 5 0 6 0
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION _J
REROOF PERMIT (406)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
• 180 DAYS FROM LASTCALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
NER'S HAZARDOUS FIRE AREA
�� YES El If yes-I understand that a Class A
M
NAME_—J )✓ ' roof assembly is required.
O L Initial I.C.B.O.s
ADDRESS EXISTING ROOF COVERING
PHONE l 0// NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS � T61E OF ROOF CPYERING
�'7��/��� �Gt /7
CITY,&ZIP i� _T/N
�/o EXISTING
PHONE BUILT-UP ROOF ❑
LICENSE /
NUMBER 7&71J9 (/ ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION Z`
I hereby affirm that I am licensed under provisions of Chapter S(commencing with Section WOOD SHAKES q
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and �Y
exact. WOOD SHINGLES U�1
License Class Lift.Number 19n
Or
Date convector OTHER(SPECIFY) V,`
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law lot the following reason. PROPOSED r9V
(Sec.7031.5,Business and Professions 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• Contmclofs License Lew(Chapter p(commencing will Sermon 7000)of Division 3 of the 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(5500).): WOOD SHAKES
C]1,as owner of the property,or my employees with wages as their sole compensation,will do ❑
the work,and the structure Is not Intended or offered for sole(Sec.7044,Business and Profes.
sions Cade: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 th rough 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 didOTHER(SPECIFY) ❑
not build or Improve for purpose of Bala.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Cade:The Contractor's 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(s)licensed pursuant to the Convector's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B&P.C.for this reason
Owner oal9
WORKER'S COMPENSATION DECLAflAT10N APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: n
❑1 neva and will maintain a Certificate of Consent to self-insure ma for Workers Compensation,which
this Building
permit Is is for by Section 3700 o1 the Labor Code,for the performance of the work for whishthis (//700 of `/J (V/„ g
permit is issued. /J Seismic
❑I have and will maithe pelf Workerrmances f the work
Insurance,as required Is
by Section Worker's
L/�1{
the Labor Code,for the performance of the work for which this permit Is Iseuatl.My Worker's 4�
Compensation Insurance cellar and Policy number are: �O/ Total
Carrier Policy No. PERMIT AUTHOR TION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed If the permit Is for one hundred dollars($100)or lase.)
1 certify that In the performance of the work for which this permit is Issued,I shall not employ
any person In any manner so ee to become subject a to orkara' ellianaatlon Laws of calf All roofs shall be insp sled prior t any r f g aterial being
fo`nla.�/�- 9 - �r installed. If a roof is installed without Irst obtaining an
Date Applicant sui . inspection,I agree to remove all new materials for inspection.
NOT shoulecame
subject2theOWorrkers'Compena IAPPLICANT: If, lon provisionis ofetheiLabor Code,you must forthwiitthbComply 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 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 rO cc rings eclass"C"or better.
spreby authorize representatives of this city to enter upon the ebova menvoned property for in. //�e ��
ep(We) purposes. A n��
(We)agree to save,pe Indemnity w and keep harmless wa the Clry of Cupertino against liabilities, -l/ /�
judgments,costs and expenses which may In any way aeras against geld City In Consequence
• of the granting of this permit. 31GNATUREAPPLICANT DAT
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