R 4989E
0
0
NUMBER R- 4 9 8 9
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APPLICATION FOR CITY OF CUPERTINO
INSPECTION DIVISION PERMI 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.
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RESIDENTIALCOMMERCIAL OTHER
OWNERS
HAZARDOUS FIRE AREA
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YES ElIf yes — I understand that a Class A
NAME J C ( e t/1 O
11111 assembly is required.
NO ❑ Initial I.C.B.O. N
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EXISTING ROOF COVERING
ADDRESS-131?(AS'Te, .r
NUMBER OF EXISTING COVERINGS S
� `" S
PHONE J O O
TO BE REMOVED TO BE RETAINED
CONTRACTQpQS '• �w �r D
NAME F l��Tl_
ADDRESSeJ O�S� oS
CITY & ZIP / 3 � �+�C
TYPE OF ROOF COVERING
EXISTING
PHONE �� U / % 2 0 ' %Z
BUILT-UP ROOF ❑
LICENSE
'J
NUMBER
ASPHALT SHINGLES El
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions 01 Chapter 8 (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license Is In full force and
enact.
4 /
WOOD SHINGLES �'r' ❑
License Claes Lic. Number s L
2 CyJ
Date Contractor
•- 1"
OTHER (SPECIFY) ` Q 10�
O `•
PROPOSED ,���'
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OWNER -BUILDER DECLARATION
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 to
permit
construct, alter, Improve, demolish, or repair any structure, prior to Its Issuance, also requires the
ur
V
BUILT-UP ROOF
for such permit to file a signed statement that he Is licensed pursuant to the provisions
JC
Elapplicant
��
of the Contractor's License Lew (Chapter a (cc .nbinB with Section 7000) of Division 3 0l the
C�
Business and Professions Code) or that ha Is mpt'iherelrom antl the beats for the alleged
ASPHALT SHINGLES ❑
exemption. Any violation of Section 7031.5,oan pplicant for a permit subjects the applicant to
e civil penalty of net more than fivphondre d Ile $SOSI). ):
❑I, as owner the propert y0mpl e I wages as their sole compensation, will do
WOOD SHAKES ❑
the work, and the etructuraJ,Ien Ime r Bred for sale (Sec. 7044, Business end Protes.
slops Code: The ConirecloP e1Is doe not apply to an owner of property who builds or
Improves
WOOD SHINGLES ❑
thereon, and who d0a work himself or through his own employees, provided that
such Improvements are not Intended or offered for sale. If, however, the building or Improvement
�--
ISBaid within one year ofcompletion, theowner-builder will have the burden ofproving that heditlOTHER
(SPECIFY) ❑ ^'C. 1 c
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 Contractor's License Law does
Q
PROVIDE I.C.B.O. REPORT NO. P
not
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 Contractor's License Law.
❑ 1 am exempt under Sec. ,B 8 P. C. for this reason
PROVIDE MFGR. 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 Worker'a Compensation,
as provided for by Section 3700 of the Labor Code, for the
�/L.� /4 C / 1 ��
ref .�f
Building%�
performance of the work for wM This
permit is Issued,
❑ have and will
havetaro Worker's
Worker's Compensation Insurance, as required by Section
d byIssued.
�p
,
$eIBmIC
-the-Labor Code, /or the Worker's 'of s
the performance the work for
of the work for which this permit Is My Worker's
Compensation Insurance carrier and and P011cy umber are:
Total
GA(12.01E� .I
Carrier�Y�l Policy NOJA)C31'�S%?
PERMIT AUTHORIZATION
DATE
CER7IFEXEMPTION FROM WORKERS'
C
Z
OM
COMPENSATION
COMPEENN SATION INSURANCE N,C.❑
(This section need not be completed If the permit Is for one hundred dollars (E100) a leas.)
I certify that In the performance of the work for which this permit Is Issued, I shall not em
any in to become �a (
All roofs shall be In ected prior to any roofing material being
parson any manner so as subject to the Workers' Componeetlon Laws of
fornia.
installed. If a roof is installed without first obtaining an
Dale Applicant
inspection, I agree to remove all new materials for inspection.
subject t. the WorkersCE TO ' Compensation previsionis of theflcate of Labor Code, Exemption,
must forthwibecome
th comply
Applicant understands and will comply with all non point
with such provisions or this permit shaipbe 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 coverings to be class "C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes.
(We) agree to eave, Indemnify and keep harmless the City of Cupertino against liabilities,
judgment., cost. and expenses which may In any way accrue against said City In consequence
SIGNATURE OF APPLICANT DATE
or the grennng 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