R 484341
OFFICE COPY
PEIT R- 4843
APPLICATION FOR CITY OF CUPERTINO NUMB E
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
01 - -
HAZARDOUS FIRE AREA
+f1
/t /v/ 0
YES ❑ If yes —I understand that a Class A
NAME f/�� ✓ !4 �� �° C.i
roof assembly is required.
NO - Initial I.C.B.O. #
/�// ,1 //� /-,r T
�/
ADDRESS ��/ 7.� ,e�lyy �"� /'
EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS
PHONE
TO BE REMOVED S61s', TO BE RETAINED
CONTRACTOR'S // ,1 /-
NAME / A�e 7 �y4zoe
ADDRESS �/ Sf
TYPE OF ROOF COVERING
��`�/
r CITY &ZIP — /�
EXISTING
Gaya
PHONE 7�
BUILT -UP ROOF ❑
NUMBER Si
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter g (commencing with Section
WOOD SHAKES
7000) of Division 3 of the Business and Professions Code, and my license Is in full force antl
effect
'
WOOD SHINGLES ❑
_
License Cles Llc. Number
2 2 G
OTHER (SPECIFY) ❑
Date contractor
OWNER - BUILDER DY15LARATIOV
PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law 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
BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the previsions
of the Contractor's License Law (Chapter g (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, y any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundi driers ($500).):
❑I, as owner of the property, o yamp 68,w lih wages as their sole compensation, will do
WOOD SHAKES ❑
the work, end the strut pre Ienot n red for sale (Sec. 7044, Business and Profes -
sions Cotle: The rector's Ligen snot apply to an owner of property who builds or
WOOD SHINGLES ❑
etl that
such Improvameras a
such Improves thereon, tllGho tlo h ffered for
for It, however,
If, however, a own emilding
building Improvement
Improvement
eq orofferetl sal .
sale. the or
or
Is sold within one pletipn; the owner- bulkierwill have the burden of proving that he did
build Improvee fa;
OTHER (SPECIFY)
�
not or purpose of sale.).
❑ I, as owner d6 he property, am exclusively contracting with licensed contractors to construct
the project (Sec. 7044, Business and Professions Coda: The Contractor's License Law does not
PROVIDE I.C.B.O. REPORT NO.
apply to an owner of property who builds or improves t hereon, and who contracts for such projects
with a contractor(s) licensed pursuant to the Contractor's License Law.
❑ I am exempt under Sec. ,B 8 P. C. for this reason
PROVIDE MFG R. INSTALLATION SPECS.
owner Date
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION
PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑ I have and will maintain a Certificate of Consent to self - Insure for Workers Compensation,
as provided for by Section 3700 of the Labor Coda, for the for
x Pd F F!
2 � �
/) D, (� U
Buildingr�_
performance of the work which this
permit Is Issued.
❑ I have and will maintain Worker's Compensation Insurance, as required by Section 3700 of
231991,
/
.Seismic — 1y1_lJ.
the Labor Code, for the performance of the work for which this permit Is Issued. My Worker's
'Compensation
c'T,
Illy
Insurance carrier and Policy number are:
Uf L.L� 4
Total
Carrier Policy No.
PERMIT A THORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' -
COMPENSATION INSURANCE
(This section need not be completed If the permit Is for one hundred dollars ($100) or leas.)
l00) o
I
/w
certify that In the performance of the work far which this permit Is Issued, I shall not employ
All roofs shall be inspected prior to any roofing ml being
any person In any manner so as to become subject to the Workers' Compensation Laws of Cell-
fornia.
- -�
"
installed. If a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
subject to the Workers' Compensation provisions of thelLaboroCode, Exemption, ou must forthwith itocomply
Applicant understands and will comply with all non point
with such provisions or this permit shaigbe deemed revoked.
Source regulations.
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
All roof verings to be cl SS "C" or better.
hereby
hereby authorize representatives of this city to enter upon the above - mentioned property for In-
purposes.
will agree to save, Indemnify and keep harmless the City of Cupertino against liabilities,
judgments, costs and expenses which may In any way accrue against said On, In consequence
$l ATURE O 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