R-4516 PERMIT R_
APPLICATION FOR •CITY OF CUPERT&O NUMBER 4 516
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK 13 NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
2 / ,F/ s- cam'
RESIDENTIAL COMMERCIAL - OTHER
OWNER'S HAZARDOUS FIRE AREA
�A u� w YES ❑ II yeaunderstand that. Class A
NAME W'IW`0.+ roof assembly is required.
' NO ❑ Initial I.C.B.O.k
ADDRESS _ 92_"V%"Its EXISTING ROOF COVERING
PHONE / NUMBER OF EXISTING COVERINGS
yy
CONTRACTOR'Sy TO BE REMOVED TO BE RETAINED
NAME ��� 9 '
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP
� EXISTING
PHONE fe J*—-2 f0 9 BUILT-UP ROOF ❑
LICENSE
NUMBER i---v/_rLI9I ASPHALT SHINGLES El
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter S(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect.
L O WOOD SHINGLES F-1
License Class 3 Lic.Number f �
Date Contractor — • OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
1 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 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 7031.5 by any applicant for a permit subjects the applicant to w N
a civil penalty of not more than five hundred dollars($5001.): OOSAKES , IC
❑ WOOD ja
I,as 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- J� H,•
.ions Code: The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES/e1�. G^" ❑
Improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for sale.If,however,the building or improvement /sr�
Is sold within one year completion,the owner-bul ldar will have the burden of proving that be did OTHER(SPECIFY,) • 1` n ❑
not build or Improve for purpose of sale.). �� 7 gs
❑l,as owner of the property,am exclusively contracting with licensed contractors to construct J
the project(Sac.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 r r f with a contractor(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 em exempt under Sac. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
C]I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, BUIIdI.,s�'
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this /�
permit is issued. �� Seismic
�Qhave and will maintain Worker's Compensation Insurance,as required by Section 3700 0l (/ x f
ilk L9bar Code,for the performance of the work for which this permit is Issued.My Worker's /O Total
Compensa/lI/9/.B�.,usra�n�Ce��tal�f�lef serf Pi Ilay number are: r�
Carrier�I✓XA_ PolicyNo. 5�• PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.p
(This section need not be completed It the permit to for one hundred dollars($100)or less.)
I certify that In the performance of the work for which this permit Is Issued,I shall not employ
any person In any manner so as to become subject to the Workers*Compensation Laws of Call. All roofs shall be inspected prior to any roofing ma erial being
tennis. 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: If,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non point
subject to the Workers'Componsation provisions of the Labor Code,you must forthwith comply pP 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 correctI agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof c enn S to be cls s"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
.Pachon purposes. . • /OS
il
(We)agree costs save,and expenses
and keep harmless the City ai Cupertino against liabilities,nce
judgments,
the granting othis permit.
which may In any way accrue against saitl Clry In consequence SI ATUR F APPLICANT 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