R 5062 (2) PERMIT R- 5062
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRAr1N
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
• IN DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
10 lJ ! RESIDENTIAL COMMERCIAL OTHER
OWNER S HAZARDOUS FIR AREA
/ YES ❑ If yes-I understand that a Class A
NAME root assembly is required.
Initial I.C.B.O.k
ADDRESS EXISTING ROOF COVERING
PHONE V11r 4W 4,M 0 NUMBER OF EXISTING COVERINGS
CONTRACT R
/�A TO BE REMOVED TO BE RETAINED
NAME ( LL
ADDRESS / COVERING
CITY 8 ZIP
EXISTING
PHONE BUILT-UP ROOF
LICENSE
NUMBER ASPHALT SHINGLE
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 9(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
Date Contractor OTHER(SPECIFY) n
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 u^G � '�i�L�
applicant for such permit to Iiia a signed statement that he Is licensed pursuant to the provisions tD
of the Contractor's License Lew(Chapter 9(commencing with See lon 7000)of Division 3 of the JI
• Business and Professions Coder'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 V
a civil penalty of not more than live hundred dollars($500).):
E]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(Sac.7044,Business and Profile-
. alone Code:The Contractor's License Law does not apply 10 an owner of property no builds or WOOD SHINGLES
improves thereon,and who does such work himself or through his awn employees.provided that
El
such Improvements are not Intended or offered for sale.If,however,the building or Improvement
Is gold 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(Sac.7044,Business and Professions Code:The Contractor's 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 contractor(s)licensed pursuant to the contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 em exempt under Sec. ,B S P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: ^ _
❑1 have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, s-I q/ Bllildin
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this �I -IVg
permit Is Issued. Seismic
1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of -rt
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's / 1 U
Compensation Insurance terrier and Policy number are: Total
Carrier Pollcy No. LA PERMIT AUTHORIZATION ot 9ATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.I]
(This section need not be completed If the permit Is for one hundred dollars($100)or less.)
I certify that In the performance of the work for which�01a permit le lea �,y�shall not em joy
any person in any manner a ail to become subject to Ifo kern'C 11;eneAtlon Lawe of�au- All roots shall be in, ected prior any roofin material being
lornl°' IF installed. If a roof is installed without first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
No cE r AP LICANT: II,after making this Cer Ificete x0
on,you should become A licant understands and will cold
subject to the Workers'Compensation provisions of the Lab Cotle,you must forthwith comply PP ply with all non point
with such provisions or this permit shell be deemed revoked. source regulations.
I certify that I have read this application and$tete that the above Information is-mect.I agree
to Comply with all city and County ordinances and state laws relating to building construction.and All fO COV rags aclass„C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spectlon purposes. '
(We)agree to save.Indemnify and keep harmless the City of Cupertino against Ilebi11tlos,
judgments.coats and expenses which may In any way accrue against said City In consequence
• of the granting of this permit. (GNATUREO A LICANT GIATE
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