R 4730 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R_ 4730
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 160 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
I
p13 4 14/v` RESIDENTIAL_.!S_COMMERCIAL OTHER
OWNERS HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME .4 Awe y/✓/A — roof assembly is required.
NO ❑ Initial I.C.B.O.#
ADDRESS EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS X
CONTRACTOR'S �(
NAME
tf'— Oy 15n—/ N G TO BE REMOVED ` TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP s•' l EXISTING
PHONE Z9>� BUILT-UP ROOF ❑
LICENSE
NUMBER Z ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect. WOOD SHINGLES ❑
License Claes_6r�7._,L_ Llc.Number x+ `
Date y 9�_Contractor G r G i{oo�i�G OTHER(SPECIFY)
OWNER-BUILDER DECLARATION �?
I hereby affirm that I am exempt from the Contractor's Licence Law for the following reason. PROPOSED
(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 Lew(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
e dull penalty of not more than five hundred dollen($500).):
❑1,as owner of theproperty,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sec,7044,Business and Profes.
alone Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑
Improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for cele.II,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Profesalons Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who build,or Improves thereon,and who contracts for such projects,
with a contractor(s)licensed pursuant to the Commences License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B$P.C.for this reason
Owner Date — APPLICATION DATE, VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
t I hereby eiilrm under penalty of perjury one of the following declaration: t'.L v /$A
U I have°ntl will maintain a Certificate of Consent to self-insure /'�V(s//�
❑ Insure for Workers Compeneatlon, Building
pe cit is Is for Section 3700 of the Labor Code,for the performance el the work for which rale
permit is leeuetl. ,Q �` 4
p v c
❑I have and will the performance
Worker's Compensation Insurance,as required by Section Workers of 990 SBISRIIC
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker, �I. /
Compensation Insurance carrier and Polis number scat N r' d„�9�� �� Total
Carrier / /t yUD Policy No.2Z6 91;fD ER IT AUTHORIZATION/ DATE
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE N.C.❑
(This section need not be completed If the permit Is for one hundred tlollere($100)or Ieemea)
I certify that In the performance of the work for which this permit Is leeuetl,I shell not ploy
any person In any manner so as,to become subject to the Woreore Compensation Laws of Cell. II roofs shall be inspected for to an fing material being
tornla. installed. It a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICsubject to Nee Worrkero''CompeTO APPLICANT: nsation proviafter sions ofthteflcate of Labor Code,Exemption,
mustufothwlllhbecome
comply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. Source regulations.
I cotlly that I have read this application and stale that the above Information Is correct.I agree
to comply with all city and county ordinances and elate laws relating to building construction.and All roof coverings to be class°C°or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes. C
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
ofthe g�enting of ihoosta ls pePmlL es which may In any way accrue against said City In consequence SIGNATURE OF APPLICANT DATE
• PRE-INSPECTION: PLYWOOD: IN-PROGRESS: -
INSIR 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