R 5056•
•
•
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R_ 5 0 5 6
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 /
/
/ ��
RESIDENTIALI.G COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
YES ❑ It yes— I understand that a Class A
NAME
roof assembly is required.
NO Ir Initial I.C.B.O. q
EXISTING ROOF COVERING
ADDRESS ,
PHONE ( 9
NUMBER OF EXISTING COVERINGS
TO BE REMOVED TO BE RETAINED
CONTRACTO 'S
NAME
ADDRESS
I
CIN 8 ZIP All
I
�. STING
r
F
PHONE
BUILT-UP RO ❑
LICENSE
NUMBER
ASPHALT SHINGLES ❑
LI ENSED CONI ORSD C ATION
I hereby affirm that t am licensed unser provisions of Chapter 8 (commencing with Section
WOOD $HAKES ,-"� ❑
7000) of Division 3 of the Business and Professions Code, and my license is In lull force and
effect.
License CIe99 Lie. Number
WOOD SHINGLES
OTHER (SPECIFY) ❑
Date Contractor
OWNER-BUILDERDECLARATIONPROPOSED
I hereby affirm that I am exempt from the Contractor's Lew for the following reason.
�
^�-, Biggs
(Sec. 7031.5, Business and Professions
s or roue
Code: Any city or county which requires a to
t
permit
improve,rep to Its Issuance also requires
_
Vr t+4r
fort to filelaa
stateir ment
BUILT-UP ROOF n
applicant such ermit signed that he Isor
licensed pursuant to the rovisions
of the Contractor's License Law (Chapter B (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he Is exempt therefrom and the basis for the alleged
Y
/�Q1.1
ASPHALT SHINGLES / y Ipcl/
exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
✓t
a civil penalty of not more than live hundred dollars ($500).):
-
r my employees
or offered wagesas
withthatsol do
❑Iden owner ofsthctureI
rBole Compensation,sand
WOOD SHAKES ' —j
the work, and the structure Is not Prlll
not tended
tl or offered far eels (Sac.
(Sec. Business antl Profen-
alone Code: The Contractors License Law does not apply to an owner of property who builds or
WOOD SHINGLES
Improves thereon, and who does such work himself or lh rough his own employees, provided that
!1��JV`///�•
such Improvements are not Intended or offered for sale. If, however, the building or Improvement
is sold within one year of completion, the owner -Wilder will have the burden of proving that he did
OTHER (SPECIFY) ❑
not build or Improve for purpose of sate.).
[ I, as owner of the property, am exclusively contracting with licensed contractors to construct
the project (Sec, 7044, Business and Profeaslons Cade: The Contractors License Lew 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,
❑ 1 am exempt under Sec. ,B & P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner Date
WORKER'S 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 Worker's Compensation,
as provided for by Section 3700 of the Labor Coda, lar the the for
^
Building
g
performance of work which this
permit Is Issued.
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1
❑ have antl will maintain Worker's Compensation Insurance, as required by Section 3700 of
�c[/'((t'
s'�
/���/.
Seismic
the Labor Cotle, for the performance of the work for which this permit Is Issued. My Worker's
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Compensation Insurance carrier and Policy number are:
I
Total
Carrier Policy No.
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed If the permit Is for one hundreq tl ar (5100) or lase.)
I certify that In the performance of the work for whltdNhl;p r I Iss. Ishell not employ
All roofs shall be inspected prior to any roofing material being
any pennon h any manner so as to becomes of It N t fcempenaadon Laws of call.
(amid'
Date Applicant
—� r
installed. If a roof- is installed without first obtaining an
inspection, I agree to remove all new materials for inspection.
NOTICE a Worker ANT: II, alter provi thl ertilicate e, you ,you should become
tons of the L r Code, you must forthwith comply
to the Workers' Compensationemithal
Applicant understands and will comply with all non point
PP p y
withssubject
with such provisions or this permit shell be tleemed revok tl.
be
SOUfCe regUIBt10t1S.
I cenlfy that I have read this application and state that the above Information is correct. agree
to comply with all city and county ordinances and state laws relating to building construction, and
All r0 C s to be class "C" or better.
hereby authorize representatives of this city to enter upon the above-mentloned property for In./
Zen
spection purposes. -
) agree neve, indemnify and keep harmless the City of Cupertino against liabilities,
111,4
jurts, caste enxpenses which may In any way accrue against said City In consequence
of tg. granting of this Permit
I TU APPLICANT 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY