R 50580
•
•
PERMIT
R_ 5 0 5 8
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
COMMERCIAL_OTHER—
xa/vRESIDENTIA
THER0
OWNER'S
NER'S
HAZARDOUS FIRE AREA
YES ❑es— I understand that a Class A
NAME
ro f assembly is requlred.
O Initial I.C.B.O. # _
�l
M
EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS
TO BE REMOVED _ TO BE RETAINED
ADDRESS/
PHONE ( Y
CONTRACTOR'
NAME �
ADDRESS „ /
TYPE OF ROOF COVERING
CITY 8 ZIPN/
EXISTING
PHONE?Vp
❑
BUILT --UP ROOFLICENSE
NUMBER
ASPHALT SHINGLES ❑
UdENISED CONTRACTORSDECLAR ION I-
I hereby affirm that I em licensed untler provisions of Chapter S (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license le In full force end
WOOD SHAKES
effect
WOOD SHINGLES
License Class LIC. Number
OTHER (SPECIFY)
Data contractor
-
OWNER -BUILDER DECLARATION
I hereby affirm that I em exempt from the Contractors License Lew for the following reason.
PROPOSED J' _
(Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to
n
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
J.',
of the Contractor's License Law (Chapter g (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
exemption. Any violation of Section 7031.5 by any applicant for a subjects the applicant to
ASPHALT SHINGLE `llh i
permit
a civil penalty of not more then five hundred dollars ($500).):
V WW 1
00
❑I, as owner of the property, or my employees with wages as their sole compensation, will do
WOOD SHAKES C'
the work, and the structure Is not Intended or offered for sale (Sac. 7044, Business and Profes.
i Ur
Ur
slons Cotle: The Contractors License Lew does not apply to an owner of property who builds or
Improves thereon, and who does such work himself or through m e own employees, provided that
WOOD SHINGLES yU, �� 1
❑
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 (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 contractors) licensed pursuant to the Contractor's License Lew.
❑ 1 am exempt under Sec. ,B B P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner
' WORKER'S COMPENSATION DECLARAATIONTION
APPLICATION DATE VALUATION
PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑ I have and will maintain a Certificate of Consent to self -insure for worker's Compensation,
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
BUllding,r�
permit Is issued,
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El have and will maintain Workers Compensation Insurance, as required by Section 3700 of
Labor Cotle, for the performance of the work for which this permit a Issued. My Workers
C
ll 1
Seismic
C o
ompeneailpn Insurance carrier and Policy number are:
I/ ltfl/�,r
Total
Carrier Policy No.
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE IN CC]
(This section need not be completed If the permit le for one hundre dgaers ($100) or less.)
(•v1
I certify that In the performance of the work for w h ihle per s isuad I shall not employ
All roofs shall be inspected prior to any rD ting ma anal being
installed. If a roof is installed without first obtaining an
any person In eny.mann so as to become ruble a t ar e' cempensatlon Lawe of call-
Cali-
fornia
c'
Date Applicant /
inspection, I agree to remove all new materials for inspection.
NOTd become
subject 2the Workers'Compefmaking
nselbn provisions ofthebar Code, a Of Exemption.
olu mustuforthwith comply
Applicant understands and will comply with all non point
with such provisions or this permit shell 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 rotating to building construction, and
All r00 CO In O aclass "C"or better ^�
hereby authorize representatives of this city to enter upon the above-mentioned property br In.
spectlon purposes,
/
(We) agree to save, Indemnity and keep harmless the City of Cupertino against Ilabillties,
NlG/
judgments, caste and expenses which may In any way accrue against Bald CityIn consequence
SGN TUBE, PPLICANT
of the granting of this permit.
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