00050053.t
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PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN IN DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
�rC� ��'
YES ❑ If yeas andreq that. Class A
NAME
assembly is
roof assembly is required.
NO ❑ Initial I.C.B.O. N
EXISTING ROOF COVE NG
ADDRESS
/��
��7
NUMBER OF EXISTING COVERINGS
ac�
PHONE
CONTRACTOR';,,,,70
BE REMOVED TO BE RETAINED
NAME /1
ADDRESS,�
TYPE OF ROOF COVERING
CITY & ZIP���
EXISTING
x
292 ��
PHONE
BUILT-UP ROOF ❑
LICENSE r/
NUMBER d
ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
hereby storm that I em licensed under provisions of Chapter 8 (commencing with Section
WOOD SHAKES
Business
of Division 3 of the Business entl Professions Code, and my license is in full force and
effect'
WOOD SHINGLES /
License Clpsa Lic. Number
Liven
V
OTHER (SPECIFY)
,.to Contractor
OWNER -BUILDER DECLARATION
PROPOSED
I hereby affirm that I am exempt from the Contractor's License Lew 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 9 (commencing with Section ]000) 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 live hundred dollars ($500).):
WOAD
0 I, as owner of the property, or my employees with wages as their sole compensation, will do
.SHAKES ❑
the work, and the structure is not intended or offered for sale (Sec. 7044, Business and Profes-
sions Cous: The Contractor's License Law does not apply to an owner of property who builds or
WOOD SHINGLESElimproves
thereon, and who does such work himself or through his own employees, provided that
such Improvements aro not intended or offered for sale. It, however, the building or tmprovement
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, 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 contractors) licensedrSe pursuant to the Contractor's License Law.
PROVIDE MFGR. INSTALLATION SPE
1 am exempt under Set. ,B 8 P. C. for this reason
exempt
(-_� &_— j 11,
r
Owner Date
APPLICATION DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I her by affirm under penally of perjury one of the 1011owing declaration:
for
7eve for Worker's Compensation,
Consent Compensation,
of to performance
and will maintain a of the
as provided for Section 3700 a Certs Lab or Code, for tospetlnsure
work for
/ '
� (jD /ti
Building
permit is issuetl.
V
(/Y
Seismic
1 have and will maintain Worker's Compensation Insurance, as required by Section 3700 of
/
the Labor Coda, for the performance of the work for which this permit is issued. My Worker's
Total
Compen n Insurance c rner antl Policy number are:
PERMIT AUTHORIZATI N
DATE
carr Policy No��/
CERTIFICA - OF EXEMPTION FROM WORKERS'
C�NPENSATION INSURANCE NZI D
(This section need not ba cam load if the permit 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 Lows of Call-
All r0 shall be inspected prior to any roofing material being
fornia,
in IIed. If a roof is installed without first obtaining an
Data Applicant
i spection, I agree to remove all new materials for inspection.
TO of Exemption,
provisions mustforthwith become
Applicant understands and will comply with all non point
ofethelcate
subjeTICE
ct to the Workers Compensatleon Laborr Code, comply
with such provisions or this permit shall be deemed revoked.
source regulations.
1 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 "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, 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICEICOPY