R 5050 (2) PERMIT R_ 5050
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION I 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
RESIDENTIAL r COMMERCIAL OTHER
ow ER's HAZARDOUS FIRE AREA
�. YES ❑ If yeas I understand that. Class A
NAME t assembly required.
NO rooInitial I.C.B.O.q
ADDRESS / x EXISTING ROOF COVERING
PHONE L• 7 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
C-NAME TO BE REMOVED TO BE RETAINED
�1
ADDRESSO/201 WIPE OF ROOF COM CITY&ZIP J/
(/ ly
PHONE /O BUILT-UP
EXISTING P ROOF
LICENSE
NUMBER ` ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter B(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 Close Lic.Number
Date contractor OTHER(SPECIFY) ❑
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 y n ;❑
applicant for such permit to Ills a signed statement that he Is licensed pursuant to the provisions BUILT-UP ROOF ti
of the Conlractols License Lew(Chapter g(commencing with Seclloo 7000)of Division 3 of the
• Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGI-44/0 19 af
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to nn,
a civil penalty of not more than five hundred dollars($500),): �„ �J�5
❑l,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES/Y � ut
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes. VV
alone Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES LU,4M
Improves thereon,and who does such work himself or through his own employees,provided that ❑
such Improvements are not Intended or offered for sale.If,however,the building or Improvement
Is sold within one year of completion,the ownerbultdar will have the burden of proving that he did OTHER (SPECIFY) 13not build or Improve for purpose of sale.).
I,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractor's License Law, PROVIDE MFGR.INSTALLATION SPECS.
[II em exempt under Sec. ,B$P.C.for this reason
Owner oats
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
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, r Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this 1/
permit Is Issued, I Seismic
1 have and wlll malntaln Workar's Compensation Insurance,as required by Section 3700 of
the Labor Cotle,for the performance of the work for which this permit la Issued.My Worker's
Compensation Insurance carrier and Policy number are: ( Total
Carier Policy No. PERMITAUTHORIZAT N DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ
(This section need not be completed If the permit Is for one hundred dollars($100)or lees.)
I certify that In the performance of the work for whlc$.ihl permit le sued,I shall not employ
any person In any manner so as to become subject h ark. ar peneation Laws of Call. All roofs shall be ingpeCted pricifflitoinyro fing material being
fornia. installed. If a roof is installed witho first obtaining an
Dale Applicant inspection,I agree to remove all new materials for inspection.
NOTI EA PLICA T: If,after making th Cerliflca i mmptlon,you should become Applicant understands and will cora p
subject to the Workers'Compensation provisions of the L or Code,you must forthwith comply PP ply with all non point
with such provisions or this permit shall be deemed revoked. Source re lations.
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 stets laws relating to building construction,and All roo cov ings obe class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spection purposes
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities,
oitlhe granting of this dgments,costs and expenses which may In any way accrue against solo Clry In consequence pe mll. S A RE9FAFTPLICANT DTE
• 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