R-5185t9
APPLICATION FOR
REROOF PERMIT
l
NAME
ADDRESS
CITY & ZIP
CITY OF CUPERTINO
INSPECTION DIVISION
(408) 777-3228
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter a (Comm encin or
]000) of Division 3 of the Business and Professions Code, and my license is In full fo e Q
effect.
License qlass J Lic. Number
KI, ly
Date Contractor
OWNER -BUILDER DECLARATION
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
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law (Chapter B (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
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 ($5001
❑ I, as owner of the property, Or my employees with wages as their sole compensation, will do
the on, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Profas.
sions Code: The Contractor's License Lew does not apply to an owner of property who builds or
Improves thereon, and who does such work himself or through his own employees, provided that
such Improvements are not intended or offered for sale. II, however, the building Or Improvement
is sold within one year of completion, the owner -builder will have the burden of proving that he did
not build or Improve for purpose of sale.).
I, as owner of the property, am exclusively contracting with licensed contractors to construct
the project (Sec. 7044, Business and Professions Code: The Contractors License Law does not
apply to an owner of property who builds or improves thereon, and who contracts for Such project$
with a contractor(s) licensed pursuant to the Contractor's License Law.
1 am exempt under Sec. ' ,B & P. C. for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
I have and will maintain a Certificate of Consent to selUnsurs for Worker's Compensation,
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
permit is Issued.
I have and will maintain Worker's Compensation Insurance, as required by Section 3700 of
_the Labor Code, for the performance of the work for which this per It Is Issued. My Workar'e
CompenaeYorylnsura acerOgpe) Policy mbar are: �1/,/y^
Carrier _K\0
CarrierPolicy No. Yv1U' VX
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need not be completed If the permit Is for one hundred dollars ($100) or less.)
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 subject to the Workers' Compensation Laws of Cali-
fornia.
Date Applicant
NOTICE TO APPLICANT: It, after making this Certificate of Exemption, you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
with such provisions or this permit shakos deemed revoked.
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 state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes.
(We) agree to save. indemnify and keep harmless the City of Cupertino against Ilsbllitlas,
judgments, costs and expenses which may In any way accrue against said City In consequence
of the arentina of this permit.
PERMIT R_ 5185
NUMBER
PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION,
RESIDENTIl COMMERCIAL OTHER
VES ❑ If yes — I understand that a Class A
roof assembly is required.
NO Initial I.C.B.O. #
EXISTING ROOF
NUMBER OF EXISTING COVERINGS
TO BE REMOVED J \ TO BE RETAINED
TYPE OF ROOF COVERING
EXISTING
BUILT-UP ROOF ❑
ASPHALTSHINGLES ❑
WOOD SHAKES
WOOD SHINGLES ❑
OTHER (SPECIFY) ❑
PROPOSED
BUILT-UPROOA�, ❑
ASPHALI*,P ES ElWOCrF%K (EES, .1 j -On„ ElWOOD SHIN(3L� '9,,#y ❑
OTHER (SPECIFY) O ❑
f
PROVIDE I.C. B.O. REPORT NO.
PROVIDE MFGR. INSTALLATION SPECS.
APPLICATION DATE( VALUATION I PERMIT FEE I
p 49 1 O //„, EXL) Buildi
Y' SBI
ry . T j�� Total
YfY?Ef�y11TA THO8IZATIONs DATE
All roofs shall be inspected prior to any roofing material being
installed. If a roof is installed without first obtaining an
inspection, I agree to remove all new materials for inspection.
Applicant understands and will comply with all non point
source regulations.
All r coverings be class "C" or better.
tel. �f
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