R-5700•
•
OFFICE COPY
PERMIT R_ 5 7 00
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
OWNER'S
HAZARDOUS FIRE AREA
!
�'
YES ❑ If yeas I andreq that B Class A
NAME /
is
roof assembly is requiretl.
assembly
NO ❑ Initial I.C.B.O.4
^
EXISTING ROOF COVERING
ADDRESS
NUMBER OF EXISTING COVERINGS
" I--( (7
PHON %j
CONTRACT 'S
^^_
TO BE REMOVED TO BE RETAINED
NAME `i
TYPE OF ROOF COVERING
ADDRESS •
CITYazIP
EXISTING
, r
2
PHONES y "�
BUILT-UP ROOF
ASPHALT SHINGLES
LICENSE
NUMBER
o
I
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 9 (commencing with Section
]000) of Division 3 of the Business and Professions Code, and my license Is in full tome and
WOOD SHAKES ❑
effect. I \ r
WOOD SHINGLES
LiceDo,. Cla Uc. Number t _i
Date � Contract r
OTHER (SPECIFY) ❑ -------r�
OWNER-BUILDERDEC RATIONPROPOSED
I hereby a irm the I am exempt from the Contractor's License Lew for the bllowing reason.
(Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the
BUILT-UP ROOF I$ Al D .
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Lew (Chapter 9 (commencing with Section 7000) of Division 3 of the
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 g �r•�)
YO ff NI
a civil penalty of not more than live hundred dollars (5500).):
WOOD SHAKES
❑ I, as owner of the property, or my employees with wages as their sole compensation, will do
the work, and the structure is not intended or offered for sale (Sec. 7044, Business and Profes.
y �,1 _
CJ! Vr UUPEKINO
slons Code: The Contractor's License Law does not apply to an owner of property who builds or
1
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] I, as owner of the property, am 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 contractors) licensed pursuant to the Contractor's License Law.
PROVIDE MFGR. INSTALLATION SPECS.
I am exempt under Sec. ,B 8 P. C. for this reason
Owner Date
APPLICATION DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
r
Building
I hereby affirm under penalty of perjury one of the fallowing declaration:
-11 have and will maintain a Certificate of Consent to self -insure for Worker's Compensation,
pee
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
Is issued.
l/,'��
�� {�
permit
'
�-I ifC
SQISmIC
❑t have and will maintain Worker's Compensation Insurance, as required by Section 3700 of
the Labor Code, for the performance of the k for which this permit is Issued. My Worker's
`�T
C on I ce car' d Policy nu at are: �k!!�
Total
IIZS
FROMW
PE HORIZATIO
DATE
CERTIFICATE EXEMPTION FROM WORKERS'
•
EN
COMPENSATION INSURANCE 100) o
(This section need not it the permit is for one hundred dollars ($100) or lasso
r antecompleted
I certify that In the performance of the work for which this permit is Issued, I shall not employ
the
any person in any me ner so as to become !ubjec a Workers' Inpensati a Lows of Cali-
fornia,
roofs all be inspected prior to any roofing material being
'
instal . If n roof is installed without first obtaining an
Data - Appunam i f ""'
ins ction, I agree to remove all new materials for inspection.
Applicant understands and will comply with all non point
PP P Y P
NOTICE Th AP LI ANT: If, aper making this Certificate of Exemption, you shoultl become
subject to the Workere' Compensation provisions of the Labor Code, you must forthwith comply
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 correct. I agree
to comply with ell city antl county ordinances and state laws relating to building construction,and
All rppppppf��...��Opppverl ngS to class"C"or better
A
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
hpoctlon purposes.
9\J�.�
(We) agree to save, Indemnify and keep harmless the City of Cupertino against liabilities,
I l/
judgments, costs and expenses which may in any way accrue against said City in consequence
SIGNATURE OF APPLICANT DATE
of the granting of this permit.
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