00050130 PERMIT
APPLICATION FOR " CITY OF CUPERTINO NUMBER R"
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3'2'28 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
iILDINGADDcEs ��t
RESIDENTIAL -COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA -
YES ❑ If yes—I understand that a Class A
NAME 02 A ,(AJ\A1DX<f roof assembly is required;
�1 1 ❑/' `` y NO ❑ Initial_ I.C.B.O.ItADDRESS \ ROOF
1 EXISTING ROOF COVERING
/1
PHONE �J� �Z� NUMBER OF EXISTING COVERINGS
CONTRACTOR'S Cc
1 � TO BE REMOVED TO BE RETAINED
NAME
ADDRESS (1 � A.10O, G TYPE OF ROOF COVERIN
CITY&ZIP
`-1 1
1 ' ,,f,Ui` EXISTING
PHONE�`'' BUILT-UP ROOF 3�
CENSE
NUMBER ASPHALT SHINGLES ❑ �Q
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES Lys
1000)of Division 3 of the Business and Professions Cotle,and my license is in lull force and
effect.
(J WOOD SHINGLES El
License Clas Lie Number
Date '31. ContractorVCM A 1 V XC.OTHER (SPECIFY) ❑
OWNER BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec.1031.5,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 10 file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Law(Chapter 9(commencing with Section 1000)of Division 3 of the
Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES ❑
exemption.Any violation of Section 1031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than live hundred dollars($500).): WOOD SHAKES/
01,as owner of the property,or my employees with wages as their sole compensation,will da ❑
the work,and the structure is not intended or offered for sale(Sec.1044,Business and Profes.
.tons Code:The Convector's License Law does not apply to an owner of property who builds or WOOD SHINGLES El '
improves thereon,and who does such work himself or through his own employees,provided that I^
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 ho did OTHER(SPECIFY)
not build or improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to Construct
the project(Sec.7(1 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 conbactoll licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owns Date WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one 01 the following declaration:
have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Building
as provided for by Section 3100 of the Labor Code,for the performance of the work for whichhich this
pe mit is issued.
ova antl will maintain Worker's Compensation Insurance,as required by Section 3100 of $eIBmID
1 Labor Cotle,for the performance of the war for which this permit is issued.My Worker's '219, 6
Compensetio Insuranc carriers Policy numb rare: ,�I Tota
Carrier PoliCyNal PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WO ERS'
COMPENSATION INSURANCE N.C.
(This section need not be completed if rho pamil is for one hundred dollars($100)or less.)
1 certify that in the performance of the work for which this permit is issued,I shall not employ
any person In any manner so as to become subject to the Workers•Compensation Laws of Cali- All roofs shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: 11,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP P Y P
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.)agree
to comply with all city and count'ordinances and state paws relating 10 building Construction, �=o
andntl be 85S r behereby authorize representatives of this city to dolor upon the above-mentioned property farr spoction purposes.
(Wo)agree to save,intlemnify antl keep harmless the City of Cupertino against liebllitids,
judgments,costs and expenses which may in any way accrue against said city in consequence SIGNATURE OF APPLICANT DATE
of the granting of this permit.
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