R 5082•
•
OFFICE COPY
PERMIT. R_ 5082
NUMBERR-
APPLICATION FOR CITY OF CUPERTINO
-
PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING
GGfADDRESSSS
Al %ll O
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
•
VES ❑ If yes — I understand that a Class A
NAME
roof assembly is required.
Initial I.C.B.O. d
EXISTING ROOF COVERING
ADDRESS
PHONE I , ®
NUMBER OF EXISTING COVERINGS
OVE
TO BE REMTO BE RETAINED
CONTRALTO
NAME
ADDRESS %
CIN 8 ZIP vL
EXISTING
a �
PHONE
BUILT-UP ROOF
LICENSE
NUMBER
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am 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 full force and
WOOD SHINGLES
License Class Lie. Number
OTHER (SPECIFY) ❑
PROPOSED
Date Contractor
OWNER -BUILDER DECLARATION
I hereby
affirm that I em exempt from the Contractor's License Law for the following reason.
(Sec. 7031.5, Business and Proleselons 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 ROOF ❑
applicant for such permit to file s signed statement that he Is licensed pursuant to the provisions
lProf License Lew (Chaplet a (commencing with Section 7000) of 3 of the
of theBusiness
ss and
end Professions Code) or that he Is exempt and the for the
basis for the alleged
ASPHALT SHINGLES
e
exemption. Any of Section 7031.5 by any s far a permit subjects the applicant to
applicant su
civil pen, fviolationtmore
e civil penalty of not more,han live hundred dollars ($500).):
1$500).
C] 1, as owner of the property, or my employees with wages as their sole compensation, will do
WOOD SHAKES
the work, and the structure is not Intended or offered for sale (Sec. 7044, Business and Profes-
sions Code: The Contractor's License Law does not apply to an owner of property who builds or
improves does
WORD SHINGLES
thereon, and who such work himself or through his own employees, provided that
P
such Improvements are not intended or offered for sale. If, however, the building or Improvement
Is sold within one year of completion, the owner-bultdar will have the burden of proving that he did
OTHER (SPECIFY) - El
build or Improve for purpose of sale.).
❑ L as owner of the property, am exclusive contracting with licensed contractors to construct
the project (Sec. 7044, Business and Professions Code: The Contractors License Law does not
]ry[
p� 11J70
PROVIDE I.C.B.O. REMFa NO. J
apply to an owner of property who builds or Improves thereon, and who contracts for such projects
with a contractorts) licensed pursuant to the Contractor's License Law,
PROVIDE MFG R. INSTALLATIQN
❑ 1 am exempt under Sec. ,B 8 P. C. for this reason
i$PEC$.
kill I v,
Owner Data
WORKER'S COMPENSATION DECLARATION
APPLICATION TE
VALUATION
PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑ I have and will maintain a of Consent to for Worker's Compensation,which
_
01
Performa
as provided for by Section 3700 01 the Lebon Coda, for the performance of the work for which Ihls
of thel Lab his
p
permit is and
❑ have entl will Workers Insurance, as required by 3700's
A
Li/✓//,
1,1)
�^
Buildings
,
Seismic ��
themaintainrt
the Labor Code, for the performance of the work lar which this permit Is Issued. My Workers
f the work for d. Myo
�
Compensation Insurance carrier end Policy number are:
1
Total
Carrier Policy No.
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.El
(This section need not be completed if the permit is for one hundred d ars ($100) or less.)
I
certify that in the performance of the work for whit this per it tl, I shell not employ
All roofs'Shall be ins acted prior to any ro ting material being
installed. If a roof is installed without first obtaining an
any panic In any manner to become subj a after ' o emanon Laws of Cali.
fathis.
Date Applicant
inspection, I agree to remove all new materials for inspection.
eabjedoine APPLICANT:
o k �eCBompeosatlon p�ovisione of m1elLeborCotlemyolu mustufodhwllthbecome
amply
Applicant understands and will comply with all non point
with such provisions or this permit shall 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 relating to building construction, and
All roo o rings 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 Ilablloties,
judgments, costs and expenses which may In any way accrue against said City In consequence
of the granting of this permit.
S GNATURWWPPLICANT 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