R 4934PERMIT R_ 4934
APPLICATION FOR CITY OF CUPERTINO. NUMBER
INSPECTION DIVISION PERMIT EXPIRATI N
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
• WITHIN leg DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL v COMMERCIAL OTHER
OWNER'S
,
HAZARDOUS FIRE AREA
M
�'(''�
� E � �t.+�
YES ❑ If yes — I that. Class A
NAME 1
` I �
assembly is req
NO roof assembly is required.
❑ Initlal I.C.B.O. a
r
ADDRESS' E �f n6
EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS
PHONE
CONTRACOR'
{�
NAME�'E
n
//1
900 Is(/JA
TO BE REMOVED TO BE RETAINED
ra *1b �i.
ADDRESS ^ ¢ 4 u g A�NJ—/r II �n�
CITU 6 ZIrP¢r�—co 170 L /
EXISTING TYPE OF ROOF COVERING
1
PHONE���
BUILT-UP ROOF ❑
NIUMBER 5-7707-7
ASPHALT SHINGLES 24\
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter a (commencing with Section
WOOD SHAKES ❑
7000) of Division 3 of the Business and Professions Cotle, and my license is In lull force and
enact.
WOOD SHINGLES 1:1License
CIe9 Llc. Number
OTHER (SPECIFY) ❑
Date Contractor �
OWNER-BUILDER DECLARATION
PROPOSED
I hereby firm t at I am exempt from the Contractor's License Law for the following reason,
Q
(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 Q t❑
applicant for such permit to IIIc a signed statement that he Is licensed pursuant to the provisions
q Q96
of the Contractor's License Law (Chapter a (commenc .with Section 7000) of Division 30l the
Business and Professions Code) or that he is axe refroe'and the basis for the
\+
ASPHALT
alleged
exemption. Any violation of Section 7031.6 by any applic tfor a permit subjects the applicant to
SHINGLES
`U Axyy
e civil penalty of not more men 11 undna a era (S50
❑ I, as owner of the proper ormy employs a their sole compensation, will do
WOOD SHAKES ❑ Vu
the work, antl the euucNreh' t Intended 1 sale (Sec. 7044, Business entl Profen
alone Code: The ContrectaA$ L L n t apply to an owner of property who builds or
Improves
yr
WOOD SHINGLES CJ ❑
thereon, entl who tloee ci rk ImeeliI through his own employees, provided that
such improvements ere not Intend or offered for sale. If, however, the building or Improvement
Is Sold within one year of completion, the own er-bulltlor will have the burden of proving that he the
OTHER (SPECIFY) ❑
not build or Improve for purpose of sale.).
01, as owner of the property, am exclusively contracting with licensed contractors to construct
the project (Sec. 7044, Business and Professions Code: The Contractors 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.
❑ I am exempt under Sec. ,B $ P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner oats
WORKERS COMPENSATION DECLARATION
APPLICATI N DATE
VALUATION
PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
O
❑ 1 have and will maintain a Certificate of Consent to sel6insure for Workers Compensation,
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
per
1
Il ��
J
Buildin g
ave and will maintain Workers Compensation Insurance, as required by Section 3700
S
Seismic
of
the Labor Code, for the performance of the work for which this permit Is Issued. My Workers
Carrier etl eu ncecar rendPollc krepe:
S
I
Total
Carrier E NNb a. 1373 p
PERMIT AUTHORIZATION
DATE
FPolicyROM
CERTIFICATE EXEMPTION FROM WORKERS'
�4
� {�
EN
COMPENSATION INSURANCE NCO
(This section need not be completed II the permit Is for one hundred dollars ($100) or lase.)
1 certify that In the performance of the work for which this permit Is Issued, I shall not employ
All roofs shall be inspected prior to any roofing material being
any person in any manner so as to become subject to the Workers' Compensation Laws of Cali.
fornia.
installed. If a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
NOT CE TO APPLICANT: ,become
subject t. the Workors' Compefnsatla`n previsionmakinis of Chef 1Labor Code, cate yoof Exemlu must to thwllth comply
Applicant understands and will Comply With all non point
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 correct. I agree
to comply with all city and county ordinances and state laws relating to building construction, and
Il roof overings CI .0-or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes.
(We) agree to save, Indemnity and keep harmless the City of Cupertino against liabilities,
judge encs, co and es which may in any way accrue against said Cityin consequence
of this expels
OF APPLICANT DA IIIIE
PRE-INSPECTION:
PLYWOOD: VIN-PROGRESS:
"
INSP. DATE
INSP. DATE
INSP. DATE
TEAR OFF INSPECTION:
BATTENS: -
FINAL:
INSP. DATE
INSP.—DATE—
INSP. DATE
NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY