R 5061 PERMIT R_ 5 0 61
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOFPERMIT (408)77-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
• 180 D YS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
es`
Z (/ RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
• YES ❑ If yes—I understand that a Class A
NAME f assembly is required.
y' N Initial I.C.B.O.R
ADDRESS l �49
// EXISTING ROOF COVERING
PHONE01r NUMBER OF EXISTING COVERINGS
CONTRACTOR
G TO BE REMOVED TO BE RETAINED
NAME
ADDRESS eI TYkE OF R06F COVERING
CITY&ZIP /ern70ge ` EXISTING -
PHONE y "v BUILT-UP ROOFLICENSE ��� 99�
NUMBER / ASPHALT SHINGLES Lu
' �r❑„V
LICENSE CONTRAC RS DECLA ATION
I hereby affirm that I em licensed under provisions of Chapter B(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and
effect. WOOD SHINGLE
License Claes US..Number
Data Contractor
OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
1 hereby affirm that I am exempt from the Contractors License Lew for the following reason.
(Sec.7031,5,Business and Professions Code: Any city or county which requires a permit to
construcapplicnt,orsuImprove,to file cornetist, air statny ement that
Is licenseor to Issuance,pursuantelstheprores the
ions BUILT-UP ROOF
applicant for such permit a Ills a Signed statement Ihat he Is licensed pursuant to the provisions
of the Contractor's License Lew(Chapter B(cammendngg with Section 7000)of Division 3 of the
• Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLE$
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).):
❑I,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 Profes.
sions 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 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) El
build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sac.7044,Business and Professions Code: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 Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sac. ,B s P.C.for this reason
Owner oats
WORKERS COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: /
❑1 have and will maintain a Certificate of Consent to self-insure for Workers Compensation, 1/l///- Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this le1�
permit e ��C W Seismic
❑I havvand e and will maintain Worker's Compensation Insurance,as required by Section 3700 of u/
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's
Compensation Insurance carrier and Policy number are: Total
Carver Policy No. PERMITAUTHORIZATIO DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N,C.I]
(This section need not be completed If the permit is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this permit is la ssdd,I shall not employ
any person in any manner so as to become subject he orkare' padsatlon Laws of Call All roofs she a insp tied prlo o an ro ing feria sing
forma—~� installed. If a root is installed without first inspection.an
Date Applicant ��
inspection,I agree to remove all new materials for inspection.
NOTICE TO PUCANT: If,after making this rtlficatay x prion,you should become
subject to the Workers'Compensation provisions of the Laebr Code,you must forthwith comply Applicant.understands and will comply with all non point
with such provisions or this permit shalllbe deemed revoked. Source regulations.
I certify that I have read this application and state that the above Information le correct,I agree
to comply with all city and county arcinances and state laws relating to building construction,and All ro Bring 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,Indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may In any way accrue against said City In consequence I ATURE LICANT
• of the granting of this permit. DTE
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