R 4780-- 7
OFFICE COPY t r _
ERT
NUMBER R- 4 7 8
APPLICATION FOR CITY OF CUPERTINO
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER''SS��
14.Qt s { U� f e� t 1 n0 J'
HAZARDOUS FIRE AREA
VES ❑ If yes I fired. Class A
NAME ^1 C[V Ste'
assembly
s is req
roof assembly is required.
NO Initial I.C.B.O. tt
[015N �&gw jt4i < I>ZW E
EXISTING ROOF COVERING
ADDRESS
NUMBER OF EXISTING COVERINGS
//''
6 `42-m-
PHONE
CONTRACTOR'S
��,)L- 1 r k.-rSL_
NAME rJtfV l C/i
TO BE REMOVED TO BE RETAINED
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ADDRESI;Ro ?5Z
TNPE OF ROOF COVERING
rS?
r u ��YS t
CITV &ZIP �P �7
EXISTING
0er'� 27- I -
\
PHONE`i
BUILT-UP ROOF ❑
LICENSE �7 6 9 4
�
NUMBER i v
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am Ilcrossd under provisions of Chapter g (commencing with Section
WOOD SHAKES
7000) of Division 3 of the Business and Professions Code, and my license is In full force and
19
affect.
WOOD SHINGLES ❑
License Claes Llc. Number
OTHER (SPECIFY) ❑
Date Contractor
OWNER -BUILDER DECLARATION
hereby affirm that I em exempt from the Contractors License Law for the fallowing reason.
PROPOSED
IS7031.5, Business and Professions Code: Any city or county which requires a permit to
con struct, 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 S (commencing with SmIlon 7000) of Division 3 of the
Business and Professions Code) or ineI he le 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 civil penalty of not more than five hundred dollars ($500).):
1rh^
(;
❑I, as owner of the property, or my employees with wages as their sole compensation, will do
WOOD SHAKES ��)� ElAR v
the work, and the structure is not Intended or offered for sale (Sec. 7044, Business and Proles-
Ur f✓ Ur
Bions Code: The Contractors License Law does not apply to an owner of property who build$or
Improves thereon, and who does himself through his
WOOD SHINGLES ❑
such work or own employees, provided that
. such Improvements are not Intended or offered for sale. If, 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) 1-1not
build or Improve for purpose of safe.).
Was owner of the property, em exclusively contracting with licensed contractors to construct
ih roject (Sec. 7044, Business and Professions Code: The Contractors License Law does not
PROVIDE I.C.B.O. REPORT NO.
apply to an owner of properlywho builds or Improves thereon, and who contracts for such projects
with a contrector(s) licensed pursuant to the Contractor's License Lew.
❑ I am a mpl under Sac. ,B $ P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
norWORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION
PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑ 1 have and will maintain a Certificate of Consent to sell -insure for Worker's Compensation,
BUIIdin g
as provided for by Section 3700 of the Labor Cade, for the performance of the work for which this
permit is issued.
_��
❑ 1 have and will maintain Workers Compensation Insurance, as required by Secllon 3700 of
eISmIC
the Labor Code, for the performance of the work for which this permit Is issued. My Workers
Compensation Insurance carrier and Policy number are:
��
Total
Carrier Policy No.
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
.
COMPENSATION INSURANCE N.C.E]
(This section need not be completed If the permit Is for one hundred dollars ($100) or less.)
I certify that In the perfarmance of the work for which this permit Is Issued, I shall not employ
All roofs shat be inspected prior to any roofing t ria g
any person in any manner so as to become subject to the Workers' Compensation Laws of Can-
fornix.
Z ?.� 6 )
installed. If a roof is installed without first obtaining an
Date Applicant ID.�inspection,
I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It, after making this Certificate of Exemption, you should become
eubjoof to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
Applicant understands and will comply with all non paint
with such provisions or this permit shall be deemed revoketl.
Source regulations.
I certify that I have read this application and stele that the above information is correct. I agree
to comply with all city and county ordinances and stale 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.
(We) agree to save, Indemnify and keep harmless the City of Cupertino against liabilities,
�`� _ 1
�/ f� �• 2._
judgents, costs and expenses which may In any way accrue against said City In consequence
of thme ginning of this permit.
/ft �-i
SIGNATURE OF APPLICAN 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
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