R 5051 PERMIT R_ 5 0 51
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 COMMERCIAL OTHER
OWNERS HAZARDOUS FIRE AREA
i VES ❑ t yes—I understand that a Class A
NAME cool assembly is required.
O ❑ initial I.C.B.O.K
ADDRESS 1411temxll EXISTING ROOF COVERING
PHONE O NUMBER OF EXISTING COVERINGS
CONTRACTOR'S-
NAME—
ONTRACT 'NAME
TO BE REMOVED TO BE RETAINED
�
ADDRESS 47E IF OF C9YERING
CITY BZIP � /`� vv EXISTING
PHONE D� �1-' g�9 /�(/ BUILT-UP ROOF
LICENSE
NUMBER ASPHALT SHINGLES
LICEIIISED CONTRACTOR90ECLARATION
hereby iaffirmnion that am licBusiness
and
Pr Professions
of Chapter B(commencing In
wllh Section WOOD SHAKES
7000)of Division 3 of the Buelneae entl Prolesslene Cade,and my license Is In full force and
effect' WOOD SHINGLES
License Class Lic.Number
Date Contractor OTHER(SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors License Law for the following reason.
(See.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 ROOF
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Law(Chapter g(commencing with Section 70001 of Division 3 01110
• Business and Professions Code)or that he Is attempt therefrom and the basis for the alleged ASPHALT SHINGLE�U�+ q �'
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to d p�C
a civil penalty of not more than five hundred dollars($500).):. WOOD SHAKES��� 1,
❑I,as owner of the property,or my employees with wages as their sola compensation,will do
the work,and the structure Is not Intended or offered for sale(Sac.7044,Business and Profes. V
slons Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES LL+ `+,+ ❑
Improves thereon,and who does such work himself or through his own employees,provided that J
such Improvements are not Intended or offered for sale.It,however,the building or Improvement
Is sold within one year of completion,the owner-buffder 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,em exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code: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 contraclor]s)licensed pursuant to the Contractor's License Low. PROVIDE MFGR.INSTALLATION SPECS.
[JI am exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: w ,r
❑I neve and will maintain a of thel Lab of Consent to sell-insure for Worker's Compensation.which
this @/ I I, Building
asprovidedIs for by Section 370001 the Labor Code,for the performance of the work for which tots `�� `✓/(/I/Y/,/s p/ 1//7-
parmitisle and 1"I/ Seismic
❑ have and will themaintainrt Worker's Compensation Insurance,as required u Section 3700's
.,the Labor tiotla for the performance of the work for which this permit le issued.My Worker's
Compensation Insurance carrier and Policy number ere: � 1 Tote
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed It the permit Is for one hundred dollars($100)or lase.)
certify that In the performance of the work for, permit au shell not employ
any person in any mature so as to
become I bloc ISth orke omp nation Lewy of Cell. All roof.^.shall be petted prior to any r offing ater being
fcrnla. installed. If a roof is installed without first obtainingan
Date Applicsnl� inspection,I agree to remove all new materials for inspection.
subject to the NO E WorrkersAPPLIs'Com ensation provisions of the t or Code,you must forthwith Applicant understands and will comply with all non point
P P Y PY
with such provisions
that I have
or this permit aha ion deemed revoked. SOOrCe re atIORS.
I ceto rtify that nave readthis ordinances
state that the above Information tobuilding
is correct. agree
hereby awithuthorize
all rcityep and countyordinances and ter u on thelatln ve-me do ed property
and All r00 COV obs class"C"or better.
hereby authorize repreeentetivee of this city to enter upon the above-mentioned property ror In.
spectlon purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against llabllllles,
judgments,costs and expenses which may In any way accrue against said City In consequence
• of the granting of this permit. G ATURE O L CANT 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY