R 5047 PERMIT R_ 5 0 4 7
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
OWNER's HAZARDOUS FIRE AREA
YES ❑ If yes—I mblyunderstandreq that a Class A
NAME' / �/ ) //'�(�S � � roof assembty is required.
.// Initial I.C.B.O.If
ADDRESS
GG / EXISTING ROOF COVERING
PHONE
G f 0 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
4
G'- TO BE REMOVED TO BE RETAINED
NAME -
ADDRESS
CITY a ZIP— /7 EXISTING
PHONE /I/ _ � r/ BUILT-UP ROOF
LICENSE
NUMBER ASPHALT SHINGLES ED
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is In full farce and /
effect. WOOD SHINGLES /�^ Z
License Class Llc.Number v\
Date Contractor
OTHER(SPECIFY) ❑ /d�(r�p�
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from the Contractor's License Law 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 n ly
of the Contractor's License Law(Chapter 9(commencing with Section 70001 of Divlslcn 30l the k 0
• Business and Professions Coda)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
a civil penalty of not more than five hundred dollars($500).): n ^`xf ����
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES A
the work,and the structure is not intended or offered for sale(Sec.7044,Business and Profes-
sionsCode:The Contractors License Law does 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 Ci 1), ❑t✓u, L,,1 Htl V
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 but den 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 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 contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION 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, //////��I I Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Seismic
❑ have and will the performance
Worker's Compensation Insurance,as required by Section 3700's lr
the Labor Code,for the pertormand of the work for which this permit is issued.My Workers
,.the
Insurance carrier end Policy number ere: Total
Carrier Policy No. PERMIT AUTHORIZATION WE
CERTIFICATE OF EXEMPTION FROM WORKERS' ig
COMPENSATION INSURANCE N.C.[]
(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 whicl his ermit Is is I shall not employ
any person in any manner o as m become subje t a rkere'C pensation Laws f call- All roofs shall sect d prior to any r ofing m tens eing
rornia. installed. If a roof is installed without first obtaining an
Date ` Applicant cate of� f% — inspection,I agree to remove all new materials forinspection.
ecome
subject tot aWorkerNOVE ls'Compefnsation provisions ofthe�LebovCode,yoiu must forthwou ithcomplyApplicant understands and will comply with all non point
with such provisions or this permit shalfjbe 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 slate laws relating to building construction,and All r00 co rIn o be 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, indemnity and keep harmless the City of Cupertino against liabilities,
judgments.costs and expenses which may in any way accrue against said City in consequence
. of me granting of this permit. ZZ-46TURE,10FAPPLICANT "DAT E
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
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