R-47430
W
OFFICE COPY
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 4743
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(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
OWNER'S
HAZARDOUS FIRE AREA
/ - %
yes - I understand that a Class A
YES [:1 '1
NAME `� �'t�
roof assembly is required.
NO ❑ Initial I.C.B.O. #
ADDRESS—EXISTING
ROOF COVERING
�
NUMBER OF EXISTING COVERINGS
.-
'7
PHONE
PHONE (
CONTRA
,p
NAME COIL-
TO BE REMOVED TO BE RETAINED
ADDRESS r
Rau
TYPE OF ROOF COVERING
CITY a ZIP C A6e_1t.5 t!
ISTING
PHONE
BUILT-UP ROOF ❑
LICENSE
C 3 l.�O5.
NUMBER
ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
hereby affirm that I em licensed under provisions of Chapter B (commencing with Section
WOOD SHAKES // ❑
7000) of Division 3 of the Business and Professions Code, and my license Is In lull force and
ancon.
S� co
WOOD SHINGLES �/❑ /plfj�
License Class Llc. Number
(�
� S
Q/ OTHER (SPECIFY)
Date Contractor -
- OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
PROPOSED rJl7L��
(Sec. 7031 5, Business and Professions Code: Any city or county which requires a permit to
coplicarLorsuImprove, or re mase structure,al
prior lolls iasusnce, also requires the
quirprovisionsth
BUILT-UP ROOF ❑ i
tofildemolish, statementh,
cpplicant for such permit to file that he Is licensed pursuant the
of the Contractor's License Law (Chapter a (commencing with Section 7000) of Division 3 of the
Business and Professions Coda) or that he to 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 ($500).):
El 1. as owner o1 the property, or my employees with wages as their sole compensation, will do .
WOAD SHAKES ❑
the work, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Profea-
aloneCode:TheContractor's License Lew does not apply to an owner of property who builds or
Improves thereon, and who does such work himself or through his own employees, provided that
WOOD SHINGLES ❑
such Imp q veMonts are not Intended or offered for sale. If, however, the building or Improvement
Is sold wilt!" one year of completion, the owner -bulkier will have the burden of proving that he did
OTHER(SPECIFY) ❑
not build or improve for purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct
the project (Sec. 7044, Business and Professions Code: The Contractor's License Lew does not
PROVIDE I.C.B.O. REPORT NO.
apply to an owner of property who builds or Improves thereon, and who contracts for such projects
with a contractors) licensed pursuant to the Contractors License Law.
❑ I am exempt under Sec. ,B 6 P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner Date
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION
PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑ I have and will maintain a Certificate of Consent to self -Insure for Workers Compensation,
I
w
Building
as provided for by Section 3700 o1 the Labor Code, for the performance of the work for which this
permit is Issued.
'/$
9
71
/V/
7D O
g
J
❑ I have and will maintain Worker's Cam tion Insurance, required by Section 3700 of
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Seismic
the Labor Code, for the performance of the for which lhla permit Is Issued, My Workeh
as
'Corm
enolI aur nco carrier Icy m or are:
Total
Canter Policy No
PERMIT T
RIZATION
DATE
CERTI KATE OF EXEMPTION FROM WO TkLRS'
COMPENSATION INSURANCE N.O.❑
(This section need not be completed if the permit Is for one hundred dollars ($100) or lase.)
�J
I certify that In the performance of the work for which this permit Is Issued, I shell not employ
All r0 'nspected prior to any roofing material being
'
any person In any m nner so es to become aubjact to Ina Works Compensation Lewy of ceu-
1°`ma.
ailed. If a r of is ins" d hout first obtaining an
Data Applicant % i
inspection, lage IS, e materials for inspection.
NOTICE T APPLICANT: If, alter making this Certificate of Exemption, you should baso
subject to the Workers' Compensation provlalons of the Labor Cotle, you must forthwith c ply
Applicant antl n a comply with all non point
pp
with such provisions or this permit shal(fbe deemed revoked.
Source regal
I certify that l have read this application and state that the above Information is Corr Ll agree
to comply with all city and county ordinances and state laws relating to building con uctlon, and
All roof COV In "C" or better.
hereby authorize representatives of this city to enter upon the above-mentioned operty for in.
l
spectlon purposes.
harmless City of Cupertino
j
(We) agree to save, Indemnity and keep the gainst liabilities,
judgments, caste and expenses which may In any way accrue against said y In consequence
of the grenling of tole pcmail.
S E A LICA IT DATE
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