R 4974 PERMIT R_ 497
4 .
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'St HAZARDOUS FIRE AREA
YES ❑ If yea—I understand that a Class A
NAME roof assembly is required.
( NO ❑ Initial LCaLO.11
a
ADDRESS—
EXISTING ROOF COVERING
PHONE /`- J� NUMBER OF EXISTING COVERINGS r
CONTRACT
NAME TO BE REMOVED TO BE RETAINED
ADDRESS / TYPE OF ROOF COVERING
CITY azIP I l EXISTING
PHONE ` BUILT-UP ROOF > �
LICENSE ❑ /
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provislons of Chapter 9(commencing with Section WOOD SHAKES ❑ !
7000)of Division 3 of the Business and Profession Cotle,and my license Is In full force and
effect. WOOD SHINGLES ❑
Licene a `� Lie.Number v� I v
Dale ContreMo!
OTHER(SPECIFY)UbVA
❑
ER-BUILDERO LA I N PROPOSED
I hereby a1 um that I am exempt from the Contractor's License Law for the following re eon.\
(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 BUILT-UP ROOF
applicant for such permit to lila a signed statement that he is licensed pursuant to the provisions
Of the• Contractor's License Law(Chapter 9(commenting 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 civil penalty of not more than five hundred dollars($501 WOOD SHAKES❑I,as owner of the property,or my employees with wages as their sole compensation,will do ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Prides-
alone Code:The Contractor's License Law does not apply to an owner of property who bullae or WOOD SHINGLES
improves thereon,and who does such work himself or through his own employees,provided that ❑
such improvements are not Intended or offered for sale.If,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
Ell.as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Prote991ons Code:The Contractor's License Law does net PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractor's License Law, PROVIDE MFGR.INSTALLATION SPECS.
E]I am exempt under Sec. ,B$P.C.for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
1 hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, Building
y J
as provided for by Section 370001 the Labor Code,for the performance of the work for which this
permit Is Issued.
1��� —� Seismic
❑1have ane will maintain Worker's Compensationa woor Insurance,eerequired su Sectionorke's / l ` l
4 the Labor Coda,for the performance of the work for w ch ihle permit Is leauetl.My Worker's
Comps I urance r randP number are: I I ( Total
7 J "
Da`d °ct'NO PERMIT AUTHORIZATION DATE
CERTIFICAT OF EXEMPTION FROM WORKERS'
COMPENSATIONif theINSURANCE
(Tela section need not r antecompleted
the
It the permit Is for one hundred tlollere
1 certify that In the performance of the work for whim this permit Is issued I shell not am toy
any person I any a ner so as to become subject to the Workers'Compen 611 n Laws of Call. All roofs shall be insp prior to any roofing material being
fainCar installed. If a roof is installed without first obtaining an
Date �ICfl
ppllcant inspection,I agree to remove all new materials for inspection.
NOTICE ter making this Car locate of Exemption you a oultl atom q licant understands and will tom I with all non Olnt
subject tp fit tion provisions of the Labor Code,you et ferihwld eompl PP comply p
with such provisions or this permit shall be deemed revoked. Source regulations.
I certify that I have read this application and state that the above Information le correct,I agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof coverings to CIaSS"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 end keep harmless the City of Cupertino aKginet liabilities,
judgments,costa and expenses which may In any way accrue against said City In consequence
• of the granting of this permit. SIGNATURE OF APPLICAN AT
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