R 5049 (2) PERMIT R_ 5049
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1W DAYS OF PERMIT ISSUANCE OR
• 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS /�
/ RESIDENTIAL ! COMMERCIAL OTHER
-
HAZARDOUS R HAZARDOUS FIRE AREA
VES ❑ If yes I understand that a Class A
NAME /•% �/ / ! /i(/ A roof assembly is required.
�j,
� //j Initial I.C.B.O.N
ADDRESS 0/ , !�v EXISTING ROOF COVERING
PHONE [ NUMBER OF EXISTING COVERINGS
CONTRACTOR'
TO BE REMOVED TO BE RETAINED
NAME e
jjjE OF ROOF COVER
ADDRESS /
CITY 6 ZIP
EXISTINGIf
PHONE BUILT-UP ROOF
CENSE
NUMBER OIz ASPHALT SHINL 8191996❑
LICENSED CONTRACTORS ECLA TI
1 hereby affirm that I em licensed under provisions of Chapter B(commencing with Section WOOD SHAKES( u vu�x.r t I till
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect WOOD SHINGLES
License Close Llc.Number
Date contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm 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 El
Cori
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 Contractors License Law(Chapter a(commencing with 9ectlon 7000)of Division 3 0l the
• Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES
exemptlon.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to !�
a 0101 penalty of not more than five hundred dollars($500).):
❑I,as owner of the property,or my employees with wages as their solo compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for eels(Sec.7044,Business and Profes-
sions Code:The Contractors License Lew 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) ❑
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 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 comrectons)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
E]I em exempt under Sec. ,B It P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby a81rm under penalty of perjury one of the following declaration:
01 have and will maintain a Certificate of Consent to sell-Insure for Workers Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is Issued.
❑I have and will maintain Workers Compensation Insurance,as required by Section 3700 of �� VI / Seismic
the Labor Code,for the performance of the work for which this permit Is Issued.My Workers
Compensation Insurance terrier and Policy number are: I Total
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need not be completed If the permit Is for one hundred dollars($100)or lees.)
I certify that In the performance of the work for which a p Milt le lee hall not employ
any person In any me or as to became subject to e w ere co enemlon Lowe of Cali. All roof.^.s ell a inspected prior t any roofi g material being
fornia. installed. If a roof is installed without first obtaining an
17
Date Applicant F inspection,I agree to remove all new materials for Inspection.
NOTI TO AP LIC If,eflar making le terillicate al em on,you should become
subject to the Workers'Compensation provisions of the Labor Me,you must forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shallibe deemed revoked. Source re9ulations.
I certily that I have read this eppticadon and stets 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 erin obe class"C"or better.
herebhereby authorise representatives of this city to enter upon the above-mentioned property for in Q/
y n purposes.
(We)agree to save,Indemnity and keep harmless the City o1 Cupertino against Ilabili les,
judgments,costs and expenses which may In any way accrue against said City In consequence
• of me granting of this perms SIGNATURE PLI ANT DATE
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
nFCIrF encu