R 4713•
•
•
OFFICE COPY
NUMBER R- 4713
APPLICATION FOR CITY OF CUPERTINO
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
IL
16
(O
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
' /
Qy
YES 0 It yes — I understand that a Class A
NAME
roof assembly is required.
NO Initial I.C.B.O. #
/ `/A
�� ��` �� ��
EXISTING ROOF COVERING
ADDRESS /7-
LtL
PHONE ,,, 1�
NUMBER OF EXISTING COVERINGS
CONTRACTOR'S /J�
NAME /.C.C.. - / ✓ /T� JU �LV C
TO BE REMOVED TO BE RETAINED
ADDRESS „[� ./e
TYPE OF ROOF COVERING
CITY a ZIP
EXISTING
7
PHONE 7
BUILT -UP ROOF ❑
LICENSE
NUMBER / (o
ASPHALTSHINGIL
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter a (commencing with Section
WOOD SHAKES ❑
7000) of Division 3 of the Business and Professions Code, and my license Is In full force and
effect,
—,
WOOD SHINGLES
License Glees Llc. Number
Data Contractor
OTHER (SPECIFY)
OWNER- LDERDEC ARATI
I hereby affirm that I am exempt from the Contractorb Lic a Law for the following reason,
PROPOSED
lase. 7031.5, Business and Professions Code: Any dry o unry which requires a permit to
construct, altar, Improve. demolish, or repair any structure, or to its Issuance, also requires the
,°�❑
BUILT-UP ROOF
applicant for such permit to file a signed statement that he is licensed pursuant to the provlelons
of the Contractors License Law (Chapter a commenclif wlth 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 ($500).):
❑I, as owner of the their do
WOOD SHAKES ❑
property, or my employees with wages as sole compensation, will
the work, and the structure Is not intended or offered for sale (Sec. 7044, Business and Profes.
alone Code: The Contractor's License Law 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
WOOD SHINGLES ❑
such Improvements ere 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.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to Construct
the project (Sac. 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,
❑ 1 am exempt under Sec. ,B $ P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner Date
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION
PERMIT FEE
I hereby affirm under penally of perjury one of the following declaration:
1 have and will maintain a Certificate of Consent to aelbineure for Workers Compensation,
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section 3700 of
` `/ 7 J
�i�D�% r� O
BUlldln g
Seismic
the Labor Cc , fort a pe I'menc8 of t work for which this permit Is Issued. My Worker's
Compensati
/
✓ -
Ineura a rier antl Pa number e: AJ/ v
Total
PERMITAUTH
DATE
Carrier PaaayNp�/�G3o3r�
CERTIFICATE OF E MPTION FROM WORKERS'
COMPEN9 ION INSURANCE N,CIO
(This section need not be completed If the per for one huntlred dollena ($100) or Ias$.)
I certify that In the performance of the work r whl h iNa permit le Issued, I shell not employ
All roofs shall a inspected prior to any roofing material being
installed. If a roof is installed without first obtaining an
any person In any annex o ae to become a ject 1 the Wo re' Compensation Laws of Call-
tattle .
/
Date Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE T AP (CANT: II, after making this Ce ate of Exemption, you should become
subject to th Werk re' Compensation prevl8lo08 A Labor Code, you must forthwith comply
A 'cant understands and will comply with all non
P P Y point
with such provisions or this permit shalGbe deems oked.
I certify that l have read this application and stet 1hatiheabove information lscorrect.I agree
S rC regul tionS. �q
�1 $,z
A
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
•-pt,
I roof OV Ing CI S C " ?r /
purposes.
(We) agree to save. Indemnify and keep harmless the City of Cupertino liabilities,
�, J(/
against
judgments, costs and expenses which may In any way accrue against said City in consequence
of the granting of this permll
SI ATUR F APPLICANT— A
PRE - INSPECTION:
PLYWOOD:
IN- PROGRESS. 11 U"
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