R-5247 (2) PERMIT R_ 5247
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3226 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN DAYS PERMIT ISSUANCE OR
WI DANSS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
V�� I RESIDENTIAL COMMERCIAL OTHER
OWNER'St HAZARDOUS FIRE AREA
YES ❑ If yes—I un erstand that a Class A
NAME root assembly is required.
G r NO ❑ Initial I.C.B.O.q
ADDRES 00 0 EXISTING ROOF COVERING
PHONE -- 8 NUMBER OF EXISTING COVERINGS 2—
CONT OFFS
TO BE REMOVED-----)�TO BE RETAINED
NAME
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP EX
ISTING
PHONEd � � l
o BUILT-UP ROOF ❑
LIICE�NNSE ASPHALT SHINGLES
NSD CONTRACTORS DECLARATION T 'S )�
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES L]
7000)of Division 3 of the EA�alress and Professions Co and my licegn Is In full force and
affect. 1L_�II/ WOOD SHINGLES FEgCl REC'0 x
Lican Cla v/1 Lie.Number
ate ( Contractor OTHER(SPECIFY) ElD
O NER-BUILDER DEC ATION CII I Vr VVrCrl lnsv
I hereby firm that I m exempt from the Contractor's License Lew for the following reaso E
(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
OI the Contractor's License Law(Chapter 9(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
e civil penalty of not more than five hundred dollars($500).): WOOD SHAKES ❑
❑I,as owner of the property.Or my employees with wages as their sole compensation,will do
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profas.
alone Code:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑
Improves 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 building or Improvement
Is sold with)n one year of completion,the owner-bulider will have the bu rden of proving that he did OTHER(SPECIFY) ❑
not bulid 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 Contractor's License Lew 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 contractor(s)licensed pursuant to the Contractor's License Lew. PROVIDE Ill INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Dale APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
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, I Building
pe mit Is Is for by Section 3700 of the Labor Code,for the performance of the work for which this
r permit is have
and I '1// /L��/1 eISmIC
have and will the pelrf Worker's Compensation Insurance,as required by Section 3700'of
s
the Labor Code,for the performance
of a work for which this permit Is Issued.My Worker's �
Comp n Insu ance c ier and Poli number are: Total
Carrier POJA I �2"� PERMIT THORIZATION DATE
CERTIFICATE OF 6 iORKERS'
COMPENSATION INSURANCE N.Q❑ n
(This section need not be completed If the permit Is for one hundred dollars($100)or less.)
I certify Net In the performance of the work for which this permit Is Issued,I shell not employ 17
any person In any manner so as to become subject to the Workers'Compena 1 n Law otad
All r00 R S e inspected prior to any roofing material being
°fA� installed. If a of is installed without first obtaining an
Dela- Applicant inspection,I agree to remove all new materials for inspection.
NOTIC TO APPL AN : If,after making this ru irate of Exemption,you sho bApplicant understands and will comply with all non OIDI
subject to he Workers'Compeneetlon provisions of the Labor Code,you must form Ith cpp p y p
with such provisions or this permit shall be deemed revoked. Source regulations.
I certify that l have reed this application and state that the above Information la correct.)
to comply with all city and county Oral nances and state laws relating to building constructioAll roof coverings to b ass„C„or better � ��
hereby authorize representatives of this city to enter upon the above-mentioned property
spection purposes.
(We)agree to save,Indemnify and keep harmless Ne City of Cupertino against liabilities,
ofjudgments,the gran costs and expenses which may in any way accrue against sem Clry inconsequence SIGNATURE OF APP ICA D E
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
OFFICE COPY