R 4972 PERMIT R_ 4972
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
ISSUANCE WITHIN 180 DAYS OF PERMIT ISNCE OR
WI DAYS FROM LAST CALLED SUA INSPECTION.
O
BUILDING ADDRESS /
RESIDENTIALCOMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
/'� VES ❑ If yes—I understand that a Class A
NAME r V roof assembly is required.
NO ❑ Initial I.C.B.O.#
ADDRESS EXISTING ROOF COVERING
PHONE. ( CYC) NUMBER OF EXISTING COVERINGS I
CONTRACT 'S
r x TO BE REMOVED I TO BE RETAINED
NAME
ADDRESSI I TYPE OF ROOF COVERING
CITY&ZIP
EXISTING
PHONE BUILT-UP ROOF 51
LICENSE
NUMBER El
SHINGLES
N CON CTOR9 DECLARATION
hereby affirm that I em licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES Cl00)of Division 3 of the Business and Profess) s Cc and my license Is In full force and
effect. WOOD SHINGLES ❑
License C es Lie.Number
Dale 11. Contractor J -
OTHER(SPECIFY) ❑
R.BUILDER D PROPOSED
I hereby adir t m exempt rom the Contractor's License Law for the following red on.
(Sec.7031.5,Business not 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 BUILT-UP ROOF
applicant for such permit to file a signed s lament that he Is licensed pursuant to the provisions
of the Contractors License Law(Chapter ommencing with Section 7000)of Division 3 of the r
Business and Professions Code)or that .exempt therefrom and the basis for the alleged ASPHALT SHINGLES ❑
exemption.Any violation of Section 7031.5b ny lipplicant for a permit subjects the applicant to
e civil penalty of not mare then nv hundred Iars'(S5oo).): WOOD SHAKES
❑I,as ownerrf lh erlygr e I pith wages as their sole compensation,will do ❑
the work,end the etr cture.b'n it Int offgred for sale(Sec.7044,Business and Proles.
slons Code;The Co Igoe$License 0mgtnotappty to an owner of property who builds or WOOD SHINGLES
Improves thereon,e w do rkhrmself or through his own employees,provided that ❑
such ImprovemenQQ a n oroXered for sale.If,however,the building or Improvement
Is sold within one ysr o 0 p lionrtba owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or ImprovAA4ppr.p po�aYsale.).
❑I,as owner of thdrproperty,am exclusively contracting with licensed contractors to construct
the project(Sec.704,Business and Professions Code:The Crntrectoes 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(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Date
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 a Certificate of Consent to sell-Insure for workers compensation, Buildingr C 9
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit Is issued.
t ❑1 neve and will melnleln Works/e Compensetl Insurance,as required by Section 3700 of 581Sm1C
the Labor Cade,for the performance of the work which this permit Is Issued.My Workers ' f,.
Compen i ' urance err' r an Icy numb r re: Total gis
Carrier PolicyN�yy _ PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPT N FROM WORKERS'
COMPENSATIONRANCE N.C.I] ^ ^^
(This section need not be completed If the permitit dollars la for one hundred dolle (3100)or lase.) r
I certify that in the performance of the work for which this permit Is Issued I shall not employ
any person In any manner so as to become suWacQo,the Workers'C peneatio i®we rl tali- All roofs shall be inspected prlo ny roofing material being
Iorni installed. If a roof is install without first obtaining an
Dale pncant inspection,I agree to remove all new materials for inspection.
NO E TO PLICA T: If,alter making this Cer1il1 of Exemption,you should become
Subject to the Workers'Compeneallon provisions of the Labor Code,you must forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shell be deemed revoked. Source regulations.
I certify that I have read this application and stale that the above Information Is correctI agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof COVl�to be class"C better.
hereby authorize representatives of this city to enter upon the abova-mentioned property for In. l
spectlpurposes.
a 1 1
(We)agree to save,Indemnify and keep harmless the City of Cupertino aelnel liabilities,
judgments.erste and expanses which may in any way accrue against sold City consequence
of he granting of mid Parma. SIGNATURE OF APPLICANT 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
OFFICE COPY