R 51570
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PERMIT R_ 515 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 LASTCALLED INSPECTION.
BUILDING ADDRESS
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RESIDENTIAL COMMERCIAL OTHER
OWNER'S
I HAZARDOUS FIRE AREA
YES ❑ If yes -1 understand that a Class A
NAME
roof assembly is required.
ADDRESS 2�� Qfj f vL�j �Q
NO Fll Inil I.C.B.O. #
EXISTING ROOF COVERING
PHONE 252- — Zr,.
/A'
NUMBER OF EXISTING COVERINGS 1
CONTRA/TOR
TO BE REMOVED TO BE RETAINED
NAME �
ADDRESS
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TYPE OF ROOF COVERING
CITY a zlPZ2-q
PHONE --L
BUILT-UP ROOF ❑
LICENSE
NUMBER —
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
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 la In full force end
effect c_
WOOD SHINGLES
LicenseClass Lic. Numbs -
2
OTHER (SPECIFY) ❑
Date Contractor
OWNER -BUILDER DECLARATION
I hereby affirm that I em exempt tram the Contractor's License Lew for the following 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
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BUILT-UP R661D ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
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of the Contractor's License Lew (Chapter g (commencing with Section 700D) of Division 3 of the
996
Business and Professions Code) or that he Is exempt therefrom and the balite for the alleged
ASPHALT/SHINGLES ❑
exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
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a civil penalty of not more than five hundred dollars ($500).1:
the
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WOOD SHAKES ulV ❑
❑I,as owner of property, or my employees with wages ee their sole compensation, will do
the work, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Protes-
alons Code: The Contractor's License Law does not apply to an owner of property who builds or
Improves
WOOD SHINGLES ❑
thereon, and who does such work himself or through his own employees, provided that
such Improvements are not Intended or offered for sale. If, however, the bulltling or Improvement
Is sold within one year of completion, the owner-bulider will have the burden of proving that he did
OTHER (SPECIFY)
not build or Improve for purpose of sale.).
01.as owner of the property, am exclusively contracting with licensed contractors to construct
the project (Sec, 7044, Business and Professions Code: The Contractor's License Lew does not
201� ^1
PROVIDE I.C.B.O. REPORT NO. J
apply to an owner of property who build$ or Improves thereon, and who contracts for such projects
with a contractor(a) licensed pursuant to the Contractors License Law,
C]1 em exempt under Sec. ,B & P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner Data
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE VALUATION PERMI
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 Workers Compensation,
as provided for by Section 3700 of the Labor Cotle, for the performance of the work for which rola
p
Building
/ I f � O SBn
IV'gl\V
htlesued,
antl wool Workers Compensation Insurance, as repulsed by Secllon of
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a bar the performance
e bon Code, for the pedormence of the work for which this permit Is lasuetl. My Workers
orke
'Compeneatlon Insurance carrier endPolicy number ere:
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Carrier Policy No.2+-
PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NAS
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(This section need not be come it the permit Is for one dollars
_
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I of the permit I.
of the work for which rola permit la sued, shell not emptoy
Is shall($100)not
certify that In meaner as
In
any person so to
any manner so as to become subject to the Work pensealon Laws of Cell-
All roofR shall be inspected prior to any roofing material being
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installed. If a roof is installed without first obtaining an
Date Appllca
inspection, I agree to remove all new materials for inspection.
subject to the Workeras'Compensation provisions of thefter makrnlghnis /1cate of Laborr Code, Exemption,
must forthwshould
ltlhbecome
comply
Applicant understands and will comply with all non point
with such provisions or this permit shalf+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 a
AT —Rif COV o be class "C" or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spectlon purposes.
(We) agree to Indemnity keep harmless the City of Cupertino liabilities,
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save, and a alnst
judgments, costa and expenses which may In any way accrue against said City n consequence
of the granting of this permit.
SIGNATURE OF APPLICANT DA
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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