R 5059•
•
a
nrctnc nnov
R- 5059
APPLICATION FOR CITY OF CUPERTINO NUMBIER
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 ADDRESSi4akOl
( �j�
RESIDENTIAL COMMERCIAL OTHER—
OWNERS
HAZARDOUS FIRE AREA
YES ❑ If yes — I understand that a Class A
NAM V
roof assembly is required.
NO Initial I.C.B.O. #
ADDRESS (f7
EXISTING ROOF COVERING _
NUMBER OF EXISTING COVERINGS
PHONE (j O
CONTRACTO 'S
�r% ✓
NAME
TO BE REMOVED TO BE RETAINED
ADDRESS /� /�JCOVERING
CITY & ZIP
EXISTING
9� 9,
PHONE _
BUILT-UP ROOF ❑
LICENSE
Q
NUMBER
ASPHALT SHINGLES _ ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 8 (commencing with Section
WOOD SHAKES r
7000) of Division 3 of the Business and Professions Code, and my license Is In full force and
effect.
WOOD SHINGLES;
License Class Lic. Number
�l
(. 4 ..
OTHER(SP,�57F'IFY)
Dale Contractor
PROPOSED "v01 w9 � �—
p
OWNER -BUILDER DECLARATION
1 hereby affirm that I em exempt from the Contractor's License Lew for the following reason,
(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 ROOF1Ur ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
the Contractors License Lew 9
� q / //'+U
of (Chapter (commencing with Section 7000) of Division 3 of the
Buslnese 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
e 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 Cotle: The Contractors License Law does not apply to an owner of property who builds or
Improves thereon, does
WOOD SHINGLES ❑
and who such work himself or through his own employees, provided that
such Improvements are not Intended or offered for sale. IL however, the bulltling or Improvement
Ie a old within one year of completion, the owner-buitdar will have the burden 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 Coda: 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 contractors) licensed pursuant to the Contractor's License Law,
-]I
PROVIDE MFGR. INSTALLATION SPECS.
C em exempt under Sec, ,B 8 P. C. for this reason
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 Workers Compensation,
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
Building
g
permit Is issued.
❑ I neve entl will maintain Worker's Compensation Insurance, as required by Section 3]00 of
un
IWJ -
d��///1
� y`v
Seismic
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:
1
Total
Carder Policy No.
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.D
(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 w this permit ued, I shell not employ
All roofs shall be inspected prior to any roofing aterial eing
any person In any manner so as to become aub]act the Workers' o pensadon Laws of calf-
forma"
1".
installed. If a roof is installed without first obtaining an
nate Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If, offer making this 6artiffc o xemtion, you should become
subject to the Workers' Compensation provisions of the bor Code, you must forthwith comply
q hcant understands and will cora
PP ply with all non point
with such provisions or this permit shal0bs deemed revoked.
Source regulations.
I certify that I have read this application and state that the above Information Is correct. I agree
city county
to comply with all city entl county of ihis ces and state laws relating to building
to buildingconstruction, and
ro veriR o be class "C" or better.
and
hereby authorize of than city to enter upon the sing
property for In
dproperty
///JJJ
sp(We) purposes.
v(( ,
(We) agree s save, Indemnify and keep harmless the City of Cupertino against In con liabilities
coats and expenses which may In any way accrue against said City In consequence
/�/
01G4NATUAE'OF
APPLICANT DATE
of the granting
of the granting of this permit.
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
nrctnc nnov