R 4900 APPLICATION FOR CITY OF CUPERTINO
NUMBER R' 4900
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(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 1 �j
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
-T-el S C l.1 YES ❑ If yes—I understand that a Class A
NAME roof assembly Is required.
' rr NO ❑ Initial I.C.B4O.e
ADDRESS
4 9 I ) h pl r EXISTING ROOF COVERING
.PHONE NUMBER OF EXISTING COVERINGS
CONTRACZ
NAME Imo.. 1 TO BE REMOVED TO BE RETAINED
ADDRESS f' S Z ' TYPE OF ROOF COVERING
CITY&ZIP EXISTING
u LJ
PHONE-- BUILT-UP ROOF ❑
LICENSES ❑
C
NUMBER C'7 ASPHALT SHINGLE
LICENSED CONTRACTORS DECLARATION \`Q
hereby affirm that I am neunder provisions of Chapter y(commencing with Section WOOD SHAKES
7000)of Division 3 of theBusiness licensed
and er provisions
Code,and rrry license is In full lone and
effect. f 56S (/� WOOD SHINGLES
License Class G Llc.Number ('
Data .5 _ 12 LJ2 Contractor D19Lx Sl — OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Lew 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 70001 of Divlelon 3 or theBusiness 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).):
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES Cl
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profae-
alone Code:The Contractor's License Law does not apply to an owner of property who bulids 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 sale,If,however,the bullding or Improvement
Is sold within one year of completion,the owner•bullder 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,em exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Profeealons 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 contrectoys)licensed pursuant to the Contractoes License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B&P.C.for this reason
OwnerDate
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of pequry one of the following declaration:
❑I have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, t� ? s Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this r�V fJ
permit Is leaned. �Ov $gISR11C
90
❑I have and will the pert rmacWorker's Compensation the work
for which ce,this as required Is
by Section 3700 0l J. 7 uTht
the Labor Code,for the performance of the work icor which ihle permit la loaned.My Workefs
Compares tion Insurance order en1d-�Policy number are: O al
Carrier S5*! � -C I_Uh n Policy No. ( � Z Y(, � PERMITAUTHORI TION DATE
CERTIFICATE EXEMPTION FROM WORKERS' VUI Cl rlllvv
COMPENSATION INSURANCE NA.O �TDn vD G`r `�
(Tele faction need not r completed II the permit Is(or one hundred dollars($100)or 1x99.) J 4 /
ortlty that in the performance of the work for which this permit Is issued,I shell not emptoy --'
any person In any manner so as to become to the Workers'Compenaetlon Laws of Call- All roofs shall be inspected prior to roofing ma rias being
fornie. q installed. If a roof is installed w' ut fir bt ining an
Date S /le Appncem inspection,I agree to remove all nUye
pection.
NOT CE subject to theOWoP Workers'Compensation tion proviafter sionls ofethelcate of Labor Code,Exemption,
mustufo thwiithbecome omply Applicant understands and willn 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 All roof coverings to be class"C"
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino a alru t liabilities, �� /rjNT r
of the granting
whish may In any way accrue against said Cltyhn consequence
e granting of this permit,
SIGNATURE OF APPLICANT DATE
S" 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