R 5048 PERMIT R_ 5048
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 �r/��/ HAZARDOUS FIRE AREA
NAME �ri/� �A///�/r �P � VES ❑ If of assembly lsta�IhaClassA
0 ImGal I.C.B.O.N
ADDRESS EXISTING ROOF COVERING
PHONE / NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME
TO BE REMOVED - TO BE RETAINED
v
ADDRESS ,�/ �� TYPE OF ROOF COVERING
CITY&zip_
€ TING
PHONE �J C BUILT-UP ROOF ❑
CENSE
NUMBER ( ASPHALT SHINGLES
UCENSEFDCONTRACTOR OECLA TI
I hereby affirm that I em licensed under provisions of Chapter B(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business end Professions Code,and my license Is In full force and
WOOD SHINGLES
License Claes I.F.Number
Dale Contractor-BUILDS
OTHER(SPECIFY) ❑
OWNER-BUILDER the LDER DECLARATION PROPOSED
hereby affirm that em exempt roles from the Contractor's or roue Lew for the fins a reason. j
(Sec.7031,5.Business and demolish,
or rep Code: Any city or county which requires a permit to
const act.sitar,Improve,tlemoileh,or repair any structure,prior to Its iaeuence,also requires the BUILT-UP ROOF G n ,❑
apiall Cant for such permit to file a signed statement that he Is licensed pursuant to the provisions qq
• of the Contractor's License Lew(Chapter g(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT
SHI NGL .Y,a yi'47C1 b
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($500).): WOOD SHAKES G�L 19gp
• ag
[11,as owner of the property,or my employees with wages as their sole compensation,will do
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes. L
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES 4.
improves thereon,and who does such work himself or through his own employees,provided that ❑
such Improvements are not intended or offered for sale.If,however,the building or Improvement `
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,em exclusively controcting with licensed contractors to construct
the project fSec.7044,Business and Professions Code:The Contractors License Low does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor($)licensed pursuant to the Contractors License Lew, PROVIDE MFGR.INSTALLATION SPECS.
0I am exempt under Sec. ,B%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 followingdeclaration:for
Wo ,
❑ have and will maintain 37 a of the
of Consent to sell-Insure for Worker's Compensation, Building
as provided for by Section 3700 of the Labor Coda,for the performance of the work tar which this ,/f
permit is leaned. U
❑ have and will the performance
Worker's Compeneetlan Insurance,as required by Section 3700's Seismic
the Labor Code,for the performance of the work for which ihls permit to Issued.My Worker's
Compensation Insurance carrier and Policy number era: Total
Carrier Policy No. PERMIT AUTHORIZATI N DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE Nco
(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 t Nch this par` N Issued,10 not employ
any portion In any manner$o as to became a Ibl to a wor is ompensadon La or can. All roofs shall b spected prior t any roofing material being
fornie. installed. If a roof is installed without first obtaining an
Date APPlicent inspection,I agree to remove all new materials for inspection.
ome
subject to the Workers'CompeICE TO APPLICANT: nsation provisionis o thefiLabor code,you must forthwithou complycomply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. Source gulations.
I certify that I have read this application and state that the above Information Is correct.I agree
to comply with all city and county Ordinance$and abate laws relating to building construction,and Al r0 I C rin f be class"C"Or better.
hereby authorise representatives of this city to enter upon the above-man1100atl property for Im
hereby
purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against Ilabllltlea,
judgments,costa and expenses which may In any way accrue against said Clry in consequence
of the granting of this permit. A URE APPLICAN
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