R 505711
11
•
PERMIT
R_ 5057
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 �^
(
RESIDENTIAL l/ COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
YES ❑ If yes —I understandIhat. Class
NAME N
sIunderstand
of
Initial I.C.B.O. g
ADDRESS
EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS
IR / O
PHONE
CONTRACTOR'
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS
CITY & ZIP f
EXISTING
PHONE
❑
BUILT-UP ROOLICENSE
jJ
NUMBER (/
ASPHALT SHINGLE
LICENSED CONTRACTORS DE
Chapter 9 (c
hereby affirm that em licensed under provisions of Cheptar 8 (commencing with Section
WOOD SHAKES ❑
7000) of Division 3 of the Business and Professions Code, and my license Is In full farce and
effect.
WOOD SHINGLES
License Class Lic. Number
L+
OTHER (SPECIFY)
Dale Contractor
m�
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
PROPOSED
(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 lasuance, also requires the
BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he le licensed pursuant to the provisions
,�
of the Contractor's License Law (Chapter 8 (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
^ ,
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).):
'
�v'I
[11. as owner of the property, or my employees with wages as their sole compensation, will do
7
WOOD SHAKES 1 ❑
q
the work, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Profes.
9
alone Code: The Contractor's License Law does not apply to an owner of property who builds or hat
reon, and oes such f or th h his
WOOD $HINGE' E$ �r
such Improveroves
offered forrk
ments areot Intended or sale. If. howeverr. the building or Improvement
Is have burden
sold within one year of completion, the owner -builder will the of proving that he did
OTHER (SPECIFY) ❑
not build or Improve for purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct
the project (Sec. 7044, Business and Professions Code: The Contractors 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 Contractor's License Law.
PROVIDE MFGR. INSTALLATION SPECS.
C]1 am exempt untler Sec. ,B 8 P. C. for this reason
Owner Date
APPLICATION DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penally of perjury one of the fallowing declaration:
❑ I have and will maintain aoftheCertificate LabofConsent toself-insure for Worker's Compensation,
for by Section 3700 of the Labor Code, for the performance of the work for which this
q
Building
g
pe mit is is
permit is issued.
,/V16�
❑ have and will maintain Workers Insurance, as requiredsu Section 370001
Seismic
Labor Cotle, for
the f the work for
the performance of the work lar which this permit is issued. My Workers
Compensetlon Insurance carrier end Policy number are:
`
Total
PERMIT AUTHORIZATION
DATE
Carder Policy No.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.p
(This section need not be Completed If the permit Is for one hundre gl re ($10() or lees.)
I certify that In the performance of the work for c th' permt Issued, I shall not employ
All roof^ shall bei petted prior to any roofing material being
installed. If a roof is installed without first obtaining an
any person In any mann so as to become subf loth orke Compansanon Laws of Cell.
forma. 11411101 IZIFA
Dole Applicant
inspection, I agree to remove all new materials for inspection.
N CE O PPL NT: It, alter mak g t e rlificole a 0110 ,you should bergme
subject to the Workers' Compensation provisions of the r Oda. you must forthwith comply
Applicant understands and will tom
pP ply with all non point
with such provisions or this permit shalObe deemed waked.
source regulations.
I certify 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 bullding construction. and
All rOdf Verl g9j to be class"C"Or better.
hereby
hereby authorize representatives of this dry to enter upon the above-mentioned property tar Int
purposes.
(We) apse to save, Indemnity and keep harmless ma City of Cupertino ainst Ilebllitles,
U////�?�`%F�,
judgments, Coate antl expenses which may In any way accrue against said DIN_n coneaquance
c N TU F APPLICANT
of the Draining of this permit.
DA TE
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