R 5054 (2) PERMITR_ 505 4
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
G(/ RESIDENTIAL COMMERCIAL OTHER
OWN R's HAZARDOUS FIRE AREA
Jn/ YES ❑ If yes—I understand that a Class A
NAME r� oof assembly is required.
dfjr// NO Initial I.C.B.O.#
ADDRESS EXISTING ROOF COVERING
PHONE / NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME TO BE REMOVED TO BE RETAINED
ADDRESS On ell
CITY&ZIP
10 ly EXISTING
PHONE v BUILT-UP ROOF -
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
herf Di affirm that am licensed under Professions
tons of Chapter S(commencing in wl.h Section and WOOD SHAKES
7000)of Division 3 of the Bualneee and under
provisions
Code,and r9 license 16 In lull force and
effect.
WOOD SHINGLES
License Class Lid.Number
Date Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sac.7031.5,Business and Professions Code: Any city or county which requires e permit to
construct,alter,Improve,demolish,or repair any structure,prior to its Issuance,also requlreethe BUILT-UP R0014U ❑
applicant for each pecan a IIIe a signed statement that he it licensed 7000)at to vi s Dro of the /� y 9
of she ss and Contractor's stone Lew(Chapter h(commencing with Section 7000)of Division 3 of the : d
•
exemption.
and violation of Code)or thet he is exempt therefrom and the basis for the applicant
to ASPHALT SHINGLES g`
a CIA Alen.Anyf violation more
al Section hundred
by any applicant for a permit subjects the appllcent to •r T (J
e civil penalty of not more Ihen five hundretl eollem($600).): r('Ur_
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES Cr)l ❑
the work,and the structure Is not Intended or allerM for sale(Sec.7044,Business and Proles-
alone Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,provided that ❑
such Improvements are not Intended or offered for sale.If,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) El
build or Improve for purpose of eels.).
❑I,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Cotle:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor($)licensed pursuant to the Contractors License Lew. PROVIDE MFGR. INSTALLATION SPECS,
[JI am exempt under Sec. ,B&P.C.for this reason
OwnerDate
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 of thel Labor
Consent toeperforma for Worker's Compensation, Building
pe mit Is Is for by Section 3700 of the Labor Code,for the performance of the work for which this n g
permit is laeuetl. (#✓/h/ Seismic
❑ have and will the performance
Worker's Compensation which this as required by Section 3700 0l x I
the Labor Code,for the Dedcrmand of the work for which this permit Is laeuetl.My Worker's
Compensation Insurance carrier and Policy number ere: Total
Carrier Policy No. PERMIT AUTHORIZATION DAT
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed If the permit Is for one hundred dollars($100)or leas.)
I Certify that In the performance of the work for whiGMIris pendd aF1"4l sued,I shall not employ
any person In any manner so as to become subject .h or aS ompensation Laws of Cell- All roofs 5 II be inspected prior to any fooling tetial Sing
rornla. installed. If a roof is installed without first btaining an
Date � Appiiaent inspection,I agree to remove all new materials or inspection.
eooerbaio �Imoda � useoinIub� pysubjtttherrke'copaoo or �alor coyyomforthwith Applicant understands and will comply with all non point
with such provislons or title permit Shall be deemed ravaked. source regulations.
I Certify that 1 have read this application and state that the some Information Is correct.I agree
to hereby authorize
rcityep and county of this city and ter up n the
t-mentll ned property
for
AIAA��7I;g1e,Class"C"Or better.
hereby aushorlEe repreeen.ellvee of title city to enter upon the shove-mentlened property for In-
spection
(We)
agrposes.
(We)agree to save,expenses
and keep harmless wit the Cly of Cupertino against Il-----e
of the gran costa and expanses which may In any way accrue against said City In consequence
. m me granting of this Parma. G ATUREf?F APPLICANT ^KATE l
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