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OFFICE COPY
PERMIT R_ 510 2
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 • I
HAZARDOUS FIRE AREA
LL
YES ❑ If yes I understand thatClass A
NAME ®L�l Q /T /'41Z -'C —
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roof assembly is required. ..
NO ❑ Initial I.C.B.O. N
/123 Z�
EXISTING ROOF COVERING
ADDRESS
PHONE"-"alNUMBER
OF EXISTING COVERINGS I�
CONTRACTOR'S
t
TO BE REMOVEDsi� TO BE RETAINED
NAME
y
I ADDRESS�.�..����
TYPE OF ROOF COVERING
CITY &21P � X
xU/�
EXISTING
PHONE '-�U�S`-
BUILT-UP ROOF
CENSE
NUMBER
ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter g (commencing with Section
WOOD SHAKES ❑
7000) of Division 3 of the Business and Professions Code, and my license Is In full force and
effect.
WOOD SHINGLES ❑
License Class Lic. Number
OTHER (SPECIFY) ❑
_
Date Contor
rac
OWNER-BUILDER DECLARATI
I hereby affirm that I em exempt from the Contractor's License Law for the fallowing reason.
PROPOSED
(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
for
BUILT-UP ROOF ❑
eppllcant 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 7000) of Division 3 of the
Business Professions
and Code) or that he Is exempt therefrom and the breis for the alleged
ASPHALT SHINGLES
exemption. Any violation of Section 7031.5 by anyapplicant fore permit subjects the applicant to
a civil penalty of not more than five hundred tloIla rs ($500).):
01, as owner of the property, or my employees with wages as their sole compensation, will do
WOOD SHAKES ❑
the work, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Proles.
sions Cotle: The Contractor's License Law does not apply to an owner of property who builds or
Improves thereon, and who does such work himself or through his own employees, provided that
WOOD SHINGLES ❑
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)
build or Improve for purpose of sale.). 1
EJ
❑ 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 dose 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 conlroctor(s) licensed pursuant to the Contractors License Law.
❑ 1 am exempt under Sec. ,B 8 P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner
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,
q
G 2 0 %n
Buildin
as provided for by Section 3700 of the Labor Code, for the performance of the work Mr which this
permit is issued.
and will maintain Workers Compensation Insurance, as required by Section 3700 of
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t (• (/� _
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y/ /
seismic
t�'have
bor Code, for the performance of the work for which this permit Is Issued. My Workers
Compensatllon
i lit
I arenCa carrier and Policy number are:
:R
,J
Total,
Carrierili4Z - — Policy No. D
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.I]
(This section need not be completed If the permit Is for one hundred dollars ($100) or lose.)
I certify that In the performance of the work for which this permit Is issued, I shall not employ
All roots Sh I be inspected prior to any roofing material being
any person In any manner so as to become subject to the Workers' Compensation Lowe of Cell-
fornia.,
installed. If a roof is installed without first obtaining an
Date -- �APPlicent /,'�
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If, alter making this Certill tltF111 xemphon,f t Id became
subject to the Workers' Compensation provisions of the Labor Code, you meet forthwith comply
Applicant understands and will comply with all non point
with such provisions or this permit shell be 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 state laws relating to building construction, and
. All roof coverings to be class Or ter.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.spection
purposes.
(We) agree to save, Indemnify and keep harmless the City Of Cupertino against liabilities,
judgments, coats and expenses which may In any way accrue against said City In consequence
K
of the granting of this permlL
S R A PU 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