R 50030
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PERMITR— 50103
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
�
i
RESIDENTIAL. _ COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
YES ❑ It yes —1 understand that a Class A
NAMEof
assemblyis required.
NO Initial LC.B.O.#
9� � �
EXISTING ROOF COVERING
ADDRESS ��.Q��
/
1 PHONEL �� —
NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME
TO BE REMOVED TO BE RETAINED
ADDRESS
TYPE OF ROOF COVERING
CITY &ZIP'
EXISTING
PHONE 7 t
BUILT-UP ROOF ❑
LICENSE
NUMBER
'"--
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter g (commencing will, Section
WOOD SHAKES El7000)
of Division 3 of the Business and Professions Code, and my license is in lull force and
effect.
License a Lic. Number 4
WOOD SHINGLES ❑
/1
U
OTHER (SPECIFY)
Daltrector
OWNER -BUILDER DECLARATION 1.11
PROPOSED
I hereby affirm that I am 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
of the Contractor's License Law (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 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).):
C-] 1, 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 Profes-
sions Code: 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 leer. I( however, the buildingofpr or improvement
year have the burden of proving that he did
1.not
OTHER (SPECIFY)
sheownerbuiltlerwlll
or
not bulltl or Improve for purpgee of sale.).
prove for purpose
1, as owner of the property, am exclusively contracting with licensed contractors to construct
the project (Sec. 7044, Business and Professions Code: The Contractors 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 ccntractor(e) licensed pursuant to the Contractor's License Law,
PROVIDE MFGR. INSTALLATION SPECS.
❑ I am exempt under Sec. ,B & P. C. for this reason
Owner Date
WORKERS 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 Consent to for Worker's Compensation,
SEP 51995
of self -insure
as provided for by Section 3700 of the Labor Code, Mr the for
Building
performance of the work which this
Is Issued,
permit
❑ I have and will maintain Worker's Compensation Insurance, as required by Section 3700 of
Seismic
the Labor ds, for the performance of the work for which this permit Is Issued. My Workers
'Comp
lion I sur ce/�der a Policy number are: �_rr/��
��
Total
1 j�/�`
erreer 1 Policy No. 146 11,d�
PERMIT AUTHORIZATION
DAJg
CERTIFICATE OF EXEMPTION FROM WORKERS'
04
COMPENSATION INSURANCE N.C.0
(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 which this permit Is Issued, I shall not employ
All roofs shall be inspected prior to any roofing material being
any person In any manner so as to become subject to the Workers' Compensation Laws of Cell-
fornia.
installed. If a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
NOT CE TO APPLICANT: If, after makinof Exemtion,
subject t. the Workers'Compenaetlon provisionis ofethe Labor Code, rtificate youu mustufo thwlithbecome comply
Applicant understands and will comply with all non point
with such provisions or this permit sha10be 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 Cov Ings 0 b 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, Indemnify and keep harmless the City of Cupertino against liabilities,
judgments, costa and expenses which may in any way accrue against said City in consequence
of the granting of this permit.
SIG URE OF APPLICANT 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
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