R 4623 PERMIT
APPLICATION FOR CITY OF CUPERTINO
NUMBERR- 4623
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
I / r
u t RESIDENTIAL COMMERCIAL OTHER
DWN 's I HAZARDOUS FIRE AREA
YES [fj If yes—1 understand that a Class A
NAME roof assembty is-required.
NO ❑ Initial I.C.B.O.If
ADDRESS l% A EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTR
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP
w _ EXISTING
PHONE _ BUILT-UP ROOF ❑, - -
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION /
I hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES of `nom/
7000) Division 3 of the Business and Professions Code,and my license Is in lull force and
effect. WOOD SHINGLES ❑
License Claes T Uc.Number
Date (SPECIFY)
ate Contractor
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec.7031.5.Business and Professions Code: Any city or county which requires a permit to J
construct,altar,improve,demolish,or repair any structure,prior to Its issuance,also requires the BUILT-UP ROOF
applicant for such permit to lila a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law(Chapter B(commencing with Section 7000)of Division 3 0l the V
Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES
exemptlan.Any violation of Section 7031.5 by any appllcant for a permit subjects the applicant to G.
a civil penalty of not more than five hundred dollars($500),):
❑l,as owner of the property,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-
sionsCode:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES 7[,
Improves thereon,and who does such work himself or through his own employees,provided that rO
such Improvements are not Intended or offered for sale.If,however,the building or improvement
Is sold within one year of complodon,the ownerbullder will have the burden of proving that he did OTHER(SPECIFY)
not build or Improve for purpose of sale.). ❑
❑1,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.t
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractors Ucense Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B 8 P.C.for this reason
Owner oats
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 self-insure for Workers Compensation, 1 'Q �� Buildin L
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this Lg
permit is issued. ic
❑1 have and will maintain Workers Compensation Insurance,as required by Section 3700 of Seismic
the Labor Cod or the performance of the work for,which this permit Is issued.My Workers ® Total
In uren carrier a Iicy numberd N
1 Ve: O Total
. Carrier Policy No/ PERMITjAU_TjHQRIZATION) DATE
'CERTIFICATE OF EX TION FROM WORKERS'
COMPENSATION INSURANCE N.C.C]
(This section need not be completed it the permit is for one hundred dollars($100)or less.)
O
I certify that in the performance of the work for which this permit is Issued,I shall not employ Os c7n
any person In any manner so as to become subject to the Workers'Compensation Laws of Cell. All roofs shall be inspected prior to any roofing material being
forma' installed. If a roof is installed without first obtaining a
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If.after making this Certificate of Exemption,you should become Applicant understands and will comply with all non
subject to the Workers'Compensation provisions of the Labor Cotle,you must forthwith comply P y point
with such provisions or this permit shall3be deemed revoked. Source regu tion$.
I certify that 1 have read this application and state that the above information Is correct.)agree
to comply With all city and county ordinances and state laws relating to building construction,and All i0of Brings 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 Ilabllltles,
jdd,ments.costs and expenses which may In any way accrue against said City In consequence
of the granting of this permit. ATUR F I ANT DATE
PRE-INSPECTION: PLYWOOD: I ROGRESS:
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