R 4671•
•
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PERMIT
R- 4671
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT 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.
BUILDING ADDRESS
4(0 3
RESIDENTIAL COMMERCIAL OTHER
OWNER'S //�
HAZARDOUS FIRE AREA
/ „`� �%,. _
��
VES ❑ 1f yes — I understand
ndthat
that a Class A
�-,0
NAME rte' c+w✓
is req
roof assemblyis
NO ❑ Initial I.C.a.O. #
ADDRESS l'JZp----
EXISTING ROOF COVERING
PHONE 95-;Z—,?77/
NUMBER OF EXISTING COVERINGS Z
2
CONTRALTO Q
•
y'�
NAME ��tit.t.J
TO BE REMOVED TO BE RETAINED
_
ADDRESSTYPE
OF ROOF COVERING
CITY & ZIP
EXISTING
0— 447q —77`�/IO
PHONE O0
BUILT-UP ROOF ❑
LICENSEf
NUMBER V G !� (o (O I
ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
hereby affirm that I am 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 full force and effect
License Class Llc. Number 4,F4 `�/
WOOD SHINGLES
�{ p'
OTHER (SPECIFY)
Date Contract
OWNER-BUILDERD LARATIONPROPOSED
I hereby affirm that l am exempt from the Contractors License Law r the Itowing 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 8 (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
a civil penalty of not more than five hundred dollars ($500).j:
E] 1, as owner of the
WOOD SHAKES ❑
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 Contractors License Law does not apply to an owner of property who builds or
Improves thereon, does himself
WOOD SHINGLES ❑
and who such work or through his awn employees, provided that
such Improvements are not Intended or offered for sale. II, however, the building or Improvement
Is sold within one year of completion, the owner -builder 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 Coda: 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(&) licensed pursuant to the Contractors License Law.
❑ 1 am exempt under Sec. ,B $ P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
OwnerDate
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 sell -insure for Worker's Compensation,
as Provided for by Section 3700 of the Labor Code, for the performance of the work for which this
ny
Building
g
permit Is Issued.
I 1 / [/
�' *S
have and will Workers Compensation Insurance, as required Section 3700 's
Seismic
the a or Code, for the pedormanca of the work for which this permit le issued. My Worker's
the performance u
'Compensation Insurance carrler entl Policy number are:
Total
�+^
Carrier (Still �'�� Policy No. A4k 2-L �T QZ—W
PERMIT AUTHORIZATION
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 issued, I shall not employ
In
All roofs shall-bbrl-rispeMed prior to any roofing material being
any person any manner so as to become subject to the Workers' Compensation Laws of Cell•
fornla.
installed. It a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
subject Il. theCE OWorrkersCC Compensation proviANT. 11. after sions ofthelcate of Laborr Code,youExemption, you should become
You must forthwith comply
Applicant understands and will comply with all non point
P y
with such provisions or this permit shal@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 w In all city and county ordinances and state laws relating to building consbuc8oa and
All roof C venin sto be class "C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
sp purposes.
(We)
(We) agree save, indemnity and keep harmless the City Cupertino egei-- liabilities,------
s ai Ci
of the a'. coats and expanses which may In any way accrue against geld City In consequence
of the granting of thispermit.
o
SIGNATUREOF APPLICANT DATE
TE
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
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