R 4734 PERMIT R_ 473
4
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN fact DAYS OF PERMIT ISSUANCE OR
N� 190 DAYS FROM LAST CALLED INSPECTION,
BUILLONG ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
i �' VES ❑ If yes—emblyunderstand requirad. ClassA
NAME /�`'� NO roof assembly is required.Initial I.C.B.O.#
ADDRESS 3 S� r ea, �G G��J EXISTING ROOF COVERING
PHONE ^ NUMBER OF EXISTING COVERINGS Z
CONTRACTOR'S �J
TO BE REMOVED L—�" TO BE RETAINED
NAME /ViT Jr
ADDRESS ,t p 2 / �vC D ,fl� TYPE OF ROOF COVERING
'
CITY aZIP—
PHONE / BUILT-UP ROOF ❑
LICENSE
NUMBER rp ASPHALT SHINGLES
(CENSE CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Coda,and my license is in full force and
effect. ; 736
WOOD SHINGLES ❑
License Class Lic.Number
S'�I -
Date 2�4 Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLAR PROPOSED
I hereby affirm that I em exempt from the Contractor's La nee Law 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 stru ,prior to Its Issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed stat emant t t Is licensed pursuant to the provisions pp
• of the Contractor's License Law SCheptsr a(common ith Section 7000)of Division 3 of the
Business and Professions Code or that ha ie exempt rafrom and the basis for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any eppIII: r a permit subjects the applicant to
a civil penalty of not more than five hundred tl0IA(115
❑I,esowneroflheproperty,ormyempl eswit eir"Is compensation,.111 do WOOD SHAKES "IA� bis 1996
the work,and the structure Is not Intends Q d ere (Se . 44,Business and Profes. - J
dons Code:The Contractor's License 4dw of e an owner of property who build$or WOOD SHINGLES
Improves thereon,and who does Grwork e r h his own employees,provided that CITY IP VU;6111 tivV
such Improvements are not Ir" do or oll)s d r e.If,however,the building or Improvement
Is sold within one year of cam shon, r or will have the burden of proving that he did OTHER
not build or Improve for purp sof a (SPECIFY)
❑
❑I,as owner of the p((ggper 6x uslvely contracting with licensed contractors to construct
the project(Sec.7044,Still d Pryfesslons Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property hbbu for improves thereon,and who contracts for such projects
with a contractors)Ilcensetl pbrs.y 10 the Contractor's License Law.
❑I em exempt under Se` ,B a P.C.for this reason PROVIDE MFGR.INSTALLATION SPECS.
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: p
❑1 have and will maintain a Certificate of Consent to sell-insure for Workers Compensation, 7 A Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this g �/
permit is Issued.El
I have and will maintain Worker's Compensation Inaurance,as requlred by Section 3700 of Seismic Labor Code,for the performance of the work for hlch this permit Is Issued.My Worker's LO�Jq" l,/
Compense,lon urenc ar r antl Policy bar re: Total
carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXE ON FROM WORKERS'
COMPENSATI NINSURANCE NCO Tn Y
(This section need not be completed If Ih p rmN Is for one huntlretl tlollare(5100)or less.) w e til,Dti CC,f %
certity that in the performance of the rk f r whim tole permit Ia Issued,I shall not employ
any person In any manner so a,10 barn sa of to h workere o p nation Laws of can. All roofs shall be inspected prix o any roofing material being
for"Ia'/ ' installed. If a roof is installed without first obtaining an
Date ( 46 Appnce inspection,I agree to remove all new materials for inspection.
rn
subject7io,ne WOTO PkeraCCompeff.
nentBon perovrlelonis ole Lobar Cotle,yolu muatu/orthwlithbcomply Appli nt understands and will comply with all non point
with such provisions or this permit shell be tleematl okad. SOU a gulations. ,
I certify that l have read this application and elate at the above Information is correct.l agree
to comply with all city and county ordinances antl ate laws relating to building construction,and AlMroovrl gsto 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,Indemnity and keep harmless the City of Cupertino against liabilities,
judgments,costa and expenses which may in any way accrue against said City In consequence
. oft a granting of this permit. SIGNATUREJqF APPLICANT 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
OFFICE COPY