R 5055 (2) PERMIT R_ 5055 -]
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
( RESIDENTIAL COMMERCIAL OTHER—
OVONWS HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Gass A
NAME roof assembly is required.
O Initial I.C.B.O.N
aooR Ss EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRALTO S
TO BE REMOVED TO BE RETAINED
NAME
f4PE OF ROOF COV
ADDRESS ,iy
CITY a ZIP EXISTING
PHONE BUILT-UP ROOF ❑
CENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION /
1 hereby affirm that I em licensed under provisions of Chapter g(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 Lie.Number
Data Contractor OTHERSPECIFY //,, 7
OWNER-BUILDER DECLARATION PROPOSED UG 1,99
I hereby a81rm 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 r /y (/I 9g6
construct,alter,Improve,demolish,or repair any structure,prior to Its issuance,also requires the BUILT-UP ROOF LVr_ ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions -'/
of the Contractor's License Law(Chapter B(commencing with Section 7000)of Division 3 of the r b)�
• 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 then five hundred dollars($500).):
❑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 Profits. rl
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 ante.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) ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,em 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)licensed pursuant to the Contractors License Lew. PROVIDE MFGR.INSTALLATION SPECS.
I em exempt under Sec. ,B&P.C.for this reason
owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby allirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to sell-insure for Workers Compensation, /d� Building
as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which this /NV' I'1
permit Is have
and `-,It
❑ have ane will the pelrf Worker's Compensation Insurance,as required by Section 3700 of $eISn11C
the Leber Code,for the performance of the work for which this permit is Iseuetl.My Worker's C
'Compensation Insurance carrier and Policy number are: Total
Carrier Policy No. PERMITAUTHORITION DATE
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 lees.)
I certify that In the penormanco of the work for which this permit qsued,I shall not employ
any person In any manner so as to become subject dth Norke yynpensabon Laws of can. All roofs shall b6linsiggel prior—t a rdofilligate ' Ing
foroIa. installed. If a roof is installed wit out first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT. If,after making this Ciurfiflcafmtxennptlon,you should become Applicant understands and will cam
subject to the Workers'Compeneatlan provisions
elQof the Labor Code,you must forthwith comply PP ply with all non point
with such provisions or this permit shbe 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 rO C aaclass"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for Iraspection purposes.
(We)agree to save,Indemnity antl keep harmless the City of Cupertino against liabilities,
judgments,casts antl expenses which may In any way accrue against said City In consequencef the granting of this permit. I TUREICANT AT
• 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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