R 5042 PERMIT R_ 5042
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1B0 DAYS OF PERMIT ISSUANCE OR
BUILDING180 DAYS FROM LAST CALLED INSPECTION.
ADDRESS �/)
30 - I/ SIDENTIAL COMMERCIAL OTHER
owNER'sHAZARDOUS FIRE AREA
V. YES [JIIf y —I understand that a Class A
NAME �00 assembly is required.
NO Initial—
I.C.B.O.N
ADDRES _,2I a KPIV EXISTING ROOF COVERING ,
I
PHON 3 2 (Y �' NUMBER OF EXISTING COVERINGS
CONTR CT '
G TO BE REMOVED TO BE RETAINED
' NAME
ADDRESS
CITY s ZIP L1 ✓ o� EXISTING
PHON(_ 00 ZZ i;`tq uc BUILT-UP ROOF _❑
LICENSE 0qlo 6-3
NUMBER C%lJ ASPHALTSHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Coda,and my license Is In lull force and
effect. /
WOOD SHINGLES �
License Class Lie.Number
Date Contractor
OTHER(SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am 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 ROOF
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions .r p
. of the Contractor's License Law(Chapter a(commencing with Section 7000)of Division 3 of the ,\�f 4 on
Business and Professions Code)or that he Is exempt therefrom and the heals for the alleged ASPHALT SHINGLES -��'7[I- 1996
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than live hundred dollars(8500).): WOOD SHAKES
E]1,as owner of the property,or my employees with wages as their sole compensation,will do ❑ I/ V
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes.
sions Code: The Contractor's License Lew dose not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,provided that ❑
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) Elnot build or improve for purpose of sale.).
❑l,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 net 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.
El am exempt under Sec. ,B B P.C.for this reason
Owner
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the fallowing declaration:
❑1 have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, gf-Building
permit Is is for by Section 3700 o1 the Labor Code,for the performance of the work(or which this �/
permitIs issued. I/Vn y(fy(J Seismic
❑I have and will maintain performance
Worker's f the work
for Insurance,as required Issued.
Sectiod.Myn 3700 of
the Labor Coda,for the performance of the work for which this permit le Issued.My Worker's
Compensation Insurance terrier and Policy number are: Total
t
Carrier Po o. PERMIT AUTHORIZATIONE
CERTIFICATE OF EXEMPTIO ON WORKERS'
` COMPENSATION U NCE N. ❑
1
This section need not be completed If the malt for one hundred dollen($1 )or le J
certify that In the performance of the k to It c Is permit Is Issued,I a not a ploy
any peso° yam,Ter a bec° a a Workers cam u- All roofs II ' petted prior to y roofing material being
°r"1B vQ �I/� installed. a roof is installed wit out first obtaining an
Date Applicant inspe ' n,I agree to remove all new aterials for inspection.
NOTICsubject loEhe WTO mkereCCompensaleon provisions ofeheflcate Labo�Codemyclu muslglat '�tlthbecome
comply A I t understands and I c ply with all non point
with such provisions or this permit shall be deemed revoked. U (ooverings
lations.
I certify that l have read this application and state that the above lnformatlo orrect.I agree
to comply with all city and county ordinances and slate laws relatingto bulldin netruction,and roof to be cla rbetter.
hereby authorize representatives of this city to enter upon the above-nitlo tl property for In-
spection
(We)purposes.
(We)sone s save,expenses
and keep harmless the e a of against
said
a against 11 ties,
• of the gran,caste and permit. which may In any way accrue against aeltl Clry In consequence
of ma granting of this permit. RE OF APPLICANT DATE
PRE-INSPECTION: PLYWOOD: IN-PROGRES .
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE INSP. DATE INSP. V DATE
NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY