R-4627 PERMIT
APPLICATION FOR CITY OF CUPERTINO
NUMB R R- 46,27
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
BUILDING
_q`DDRESS 180 DAYS FROM LAST CALLED INSPECTION.
/ �7AJ ['//
/ / RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
NAME 1. �/�✓'Y/rG ��!/- YES ❑ It yes-I understand that a Class A
root assembl is required.
�� NO Initial LC.B.O.71
ADDRESS . EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S /
NAME � 0 TO BE REMOVEDy TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP
EXISTING
PHONE BUILT-UP ROOF ❑
CENSE
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license is In lull force and
effect. C,w j �7 WOOD SHINGLES
�
License CIesS l Uc.Number J ❑
Oere Contractor OTHER(SPECIFY) El
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors License Lew for/e following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,aper,Improve,demolish,or repair any structure,prior to Its issuance,also requires the BUILT-UP ROOF ❑
of the o for such parent to fila a signed statement that g is licensed Pursuant to the provisionsofthe
of the Contractor's License Lew(Chapter 9(commencing with Section 7000)of Division 3 of the nn k
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES'D V
exemption.Any violation of Section 7031.5 by any applicant for a permit Subjects rhe applicant to
a civil penalty of not more than five hundred dollars($500).1: WOOD SHAKES 995 ❑
01,as owner of the property,or my employees with wages w their sole compensation,will do 1
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Proles.
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHIN ` �❑
improves thereon,and who does such work himself or through his own employees,provided that �N
such Improvements are not Intended or offered for sale.If,however,the building or Improvement ;t�
is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY)jr�'J ❑
not build or Improve for purpose of sale.). CIF J
I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.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 contractor(s)licensed pursuant to the Contractors License Law, PROVIDE MFGR. INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby arflrm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Building
as provided for by Section 3700 of the Labor Cotle,for the performance of the work for which this / }OD 40 p
permit is issued. ynn fJ
❑I have and will maintain Workers Compensatio Insurance,es required by Section 3700 of / Seismic _
-the Labor Code,for the pedorman a of the work r wMch this�peerr�iityt issued.My Worker's / Total
Campense' Insurn cerriera olicy num pyre:
Poll N6- ���Q��O`��
Carrier Policy PERMIT AUTHORIZATION DATE
CER IC E EXEMPTION FROM WORKERS'
COMP NSATION INSURANCE N.C.[]
(This section need not be completed It the permit' na huntlred tlollars($100)or lass.)
I certify that in the performance of the work for ich t s permi is iasuetl,I shall not employ
any person In any"f�nnerj�as to become aub t to t a W k Camp n Law of call- All roofs shall be inspected prior to any ro fing matforn erial mg
run. .e 61 / installed. If a root is installed without first obtaining an
Dare B s Applicant inspection,I agree to remove all new materials for inspection.
NOTsubject lto t e W Pkers'Compens
ation o peoiv dons o art Labote r Code,Exemption,
must forthwith Applicant understands and will comply with all non point
with each provisions or this permit shelfbe Oeemetl oketl. SOU regulations.
I certify that I have read this application and state Nat rho above Information is correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,and roof Covef gs to be cl rbetter.
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 liabilities,
judgments,costs and expenses which may In anyway accrue against said City In consequence GNATU PPLICANT DA
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