R-4679 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R— 467
9
INSPECTION DIV ISI ON PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
• 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWN R5 - - HAZARDOUS FIRE AREA
_ YES ❑ es-I untlerstand that a Class A
NAME% lY �Zf assembly is required.
NO^_ Inill LC.B.O.11
1 EXISTING ROOF COVERING
ADDRESS U�� �'%-�Mn�S N U?YI�k�U11
PHONEMBER OF EXISTING COVERINGS /
CONTRACTOR'
NAME TO BE REMOVED TO BE RETAINED
fCL'�P.A—�"Li1$/-A� �L'L 1�_ �/���✓\-C/
ADDRESSgypJ L �.�[, TYPE OF ROOF COVERING
CITY&ZlP : CC7 ID2�n Zn ji l S:�C fi t� �� EXISTING
PHONE��..1 If BUILT-UP ROOF
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ❑
7000)01 Division 3 01 the Business and Professions Code,and my license is in full force and
effect.
�� ,p WOOD SHINGLES ❑
License Class Lic.Number 60Ic ICL
Date contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION 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 provisions
. of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 0l 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 fare permit subjects the applicant to
a civil penalty of not more than Ove hundred dollars($500).): WOOD SHAKES El
theas owner of the property,or my employees with wages as their sole compensation,will do
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profes-
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES
❑
improves thereon,and who does such work himself or through his own employees,provided that
such improvements are not Intimidator offered for sale.it,however,the building or Improvement
IssoId within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) Elnot build or improve for purpose of sale.).
❑1,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 Committers License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B&R C.for this reason
Owner Date APPLICATION DATE VALUATION gEWIT EE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty 01 perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, :a BUlldl
as Is I tl for by Section 3700 of he Labor Code,for the performance of the work for which this
permit is Issued, �' `T ® ( Seism
❑I have antl will m ' sin s Compensation Insurance,as required by Section 3700 of c
the Letter Cotle,for I the work for which this permit Is Issued.My Workers f ) Total
Compensation Ins n r nd Policy number are: C7 179 —
Carrier—
Carrier Policy No. PERMIT A YFjORIZATION t DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.
(This section need not be completed if the permit is for one hundred dollars($100)Or less.)
I certify that in the performance of the work for which this permit is Issuetl, shall not employ
any person in any manner so as to become subject to the Workers'Compensation Laws of Cali- All roofs shall Be Jifispected prior to any roofing material being
fernia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It,after making this Certificate of Exemption,you should become A licant understands and will com I with all non oint
subject to the Workers'Compensation provisions Of the Labor Code,you must forthwith comply pr' p y p
with such provisions or this permit shall,,be deemed revoked. Source regulations.
I certify that I have read this application and state that the above information is COrrOC1 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 anter upon the above-mentloned property for in-
spection purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
• of the granting o1 his perrmand ilses which may In any way accrue against said City in consequence SIG LI T T
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