R 5046 (2) PERMIT R_ 5 046
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(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 7
9LGDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ II yes—I understand that a Class A
NAMEroof assembly is require
NO ❑ Ntial I.C.B.O.#
ADDRESS 2� 01o. EXISTING ROOF COVERING
PHONE J Ill 02— NUMBER OF EXISTING COVERINGS
CONTRAC R' 4 IJ+
NAME av nB 6/� G T BE REMOVED TO BE RETAINED
ADDRESS / TYPE OF ROOF COVERING
CITY&ZIP
PHONE J' BUILT-UP ROOF
LICENSE ?�a G ASPHALT SHINGLES ❑ _
NUMBER
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES El
of Division 3 of the Business and Professions Code,and my license is In full force and seen. WOOD SHINGLES
License Class Lic.Number
Data ContractorOWNER-BUILDER
OTHER (SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that em exempt from the e: Any ora License Law for the lino a reason.
(Sec.construct,
It Business and Professions Code: Any city or county which requires e permit to
construct,altar,Improve,to file demolish,or d statement
structure,prior to Its Issuance,uant also requires the BUILT-UP ROOF ❑
applicant for each permit to flaw a signed rI(oo that he is licensed pursuant to the provisions
of the ss an Pro License Lew(Chapter 9(commencing will om and 7000)of Division 3 of the
• ex
Business entl violation of Code)or that he Is exempt therefrom entl the seals(or the applicant
to ASPHALT SHINGLES
exemption.Any violation of than
five 703 1 r by any applicant for a permit subjects the applicant to
e civil penalty of not more then Ilve hundred dollars($500).):
C]I,as owner of the property,or my employees with wages as thea r sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes.
slons Code:The Contractor's License Lew does not apply to an owner of property who bulids 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.).
❑1,as owner of the property,em exclusive 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 contranons)licensed pursuant to the Contractors License Lew.
❑ PROVIDE MFGR.INSTALLATION SPECS.
I em exempt under Sec. ,B 6 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain 37a of the
abof Consent toeperinsure for Workers Compensation,
this /♦ Building
as mit Is Is for by Section 3700 of the Labor Code,for the performance of the work for which this /C(//'f / / _
permit la leeuna, ((/ t/J /7 Seismic
❑ have and will the performance
Worker's Compensation the work
for Insurance,as permit is IIs u Section Workers of
the Labor Cone,for the performance of the work roc which this permit is issued.My Workers
Compensation Insurance carrier and Polley number are: Total
Carrier Policy No. PERMITAUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM tfQAReR
COMPENSATIO NSU CE N.C.❑
(This section need not be completed If the p a for one hundr dol rs( 00)or lea I
I cattily that In the performance of the war r which this permit i la employ
any p,V.any m oar °/a to become m n Iw Lewe I Can-imDATE
roofs
h spected poo any roofing material being
any roofing material being
fornie,/ /���° � f a roof is installed wt out first obtaining an
Oete �.6 Applicen n,I agree to remov allnew
starlets for inspection.
NOTICE TO APPLICANT: If,after g this Certificate of Ex ptlon,yo hould become understands a will COm)Isubject to the Workers'Compensation provlelons of the Labor Code,youmus rthwith comply y With all non pointwith such provisions or this permit shell be deemed revoked gulations.I certify that I have read this application antl stale that the above Informatl le correct.I agree
to comply with all city and county ordinances antl state laws relating to buildi construction,andverings to be lass°C"o better.hereby authorize representatives of this city to enter upon the above-mentl atl property for In.
spection purposes.(We)agree Io save,Indemnlly entl keep harmless the City of CupertinoagainstIlebllitlea,judgments,coats end expenses which may In any way accrue against said City In consequenceof the granting of this permit. RE OF APP CANT DATE
PRE-INSPECTION: PLYWOOD: IN-PROGRES
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