R 49240
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PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R_ 49 2 4
INSPECTION DIVISION PERMITEXPIRATION
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
INl
dp r y may -
are,
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
11
YES yes -I understandihat a Clam
NAME �(V ��r `
'oof assembly is required;
NO Inl I.C.B.O. N
��l 1 `
ADDRESS �il"J
EXISTING ROOF COVERING
PHONE
NUMBER OF EXISTING COVERINGS (�
CONTRACTOR'S
NAM Q C
TO BE REMOVED TO BE RETAINED
ADDRESS
I
TYPE OF ROOF COVERING
CITY &ZIP - 1
EXISTING
��� (�
PHONE—
BUILT -UP ROOF ❑
LICENSE
NUMBER
ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B (commencing with Sect
WOOD SHAKES ❑
7000) of Division 3 of the Business and Professions Code, and my license le In lull for
effect '� 12r'
`7S—
WOOD SHINGLES ❑
License Clara Uc. Number
OTHER (SPECIFY) ❑
Date CSUmotor
OWNER. BUILDER DECLARAT ON
hereby
PROPOSED
I affirm that I am exempt from the Contractor's License Law f tho following reason.
(Sec. 7031.5, Business and Profession& 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 Ille a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Law (Chapter 8 (commancing,With Section 7000) of DIvl9lon 3 of the
Business and Professions Code) or that he Is exemppMer rom and the basis for the alleged
ASPHALT SHINGLES
exemption. Any violation of Section 7031,5 by any applicant a permit subjects the applicant to
• civil penalty of not more than five hundred dollars ($509)J!
❑I, as owner of the property, or my employees Ithwages a their sole compensation, will do
WOOD SHAKES ❑
the work, and the structure Is not Intended or all Of fOrs I ec 7044, Business and Profes-
sions Code: The Contractors L is Law tludan ep t builds
If or of property who or
Improves thereon, and wh a such work hlm0e1 r o hi n employees, provided that
WOOD SHINGLES ❑
such Improvement& are ng IntendsDD or offered r If owevaa the building or Improvement
Is
sold within one year of co pletiox he a I have the burden of proving that he did
build Improve for
OTHER (SPECIFY) ❑
not or purp a of a a.
[D I, as owner of the pro an e I Ively contracting with licensed contractors to construct
the project (Sec. 7044, Bu ntl , Iessions Code: The Contractor's License Law does not
PROVIDE I.C.B.O. REPORT NO.
apply to an owner of proper he ullm or Improves thereon, and who contracts for such projects
with a contmctods) licensed,, p ns nt to the Contractors License Law.
C] I am exempt under Sec. ,S It P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner Date COMPENSATION DECLARATION
WORKER'S '
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 Worker's Compensation,
Building
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
per Is Issued.
_
nn „y
' flnp_,
11 have Worker's
,� rte+ U
�I� -Mv,�
SeISmIC k
end will maintain Compensation Insurance, as required by Section 3700 of
Ih Labor Coda, for for
1 ,
the performance of the work which this permit Is Issued. My Worker's
Carrier eurenc eemer and Polleynulaberere:
C
Total
-
Carrier �_ Policy No.
IT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
rt •" .a I
�(
COMPENSATION INSURANCE N.C.O
(This section need not be completed If the permit Is for one hundred dollars ($100) or lase.)
I certify that In the performance of the work for which this permit Is Issued I shell not emptoy
any In become
All roofs shall be inspected prior fo any r off g aterial being
parson any manner so as to subject to the Workers' Compensation Laws of Cell-
lornia.
installed. If a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
Applicant understands and will comply with all non point
pP P Y P
with such provisions or this permit shell 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
II roof COVerinAlo orb Her.
hereby authorize representatives of this city to enter upon the abovo- montlaned property for in.
spection purposes.
(We) agree to save, Indemnify end keep harmless the City of Cupertino against liabilities,
LlasC"
^ c.
/_J1
w
judgments, coats and expenses which may In any way accrue against said City In wneequence
pen
of me granting of permit
SIGNATURE OF P
L NT DATE
PRE- INSPECTION:
PLYWOOD:
IN G ESS:
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