R-4550 PERMIT R_ 4550
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (406) 777-3226 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
1 W DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS j //�� ,'//�/ �/
,Ab, �/ `j'�ri�(�//'y ��/ RESIDENTIAL COMMERCIAL OTHER
OWNER'S / /' HAZARDOUS FIRE AREA
.�� ` 12 VES ❑ IIyessIunderstandthat. ClassA
NAME roof assembly is required.
NO ❑ Imhal LC.B.O.11
EXISTING ROOF COVERING
PHONE - Z O NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
�/S ���r 5�67���� ( ��'•^I TO BE REMOVED TO BE RETAINED
NAME
ADDRESSG� '/ TYPE OF ROOF COVERING
CITY&ZIP d2� ,"z ����/� `�
4,/'r/,0 - 0 6 s7 BUILT-UP
STING
PHONE BUILT-UP ROOFLENSE ❑
NUMBER J l /3 ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is in lull force and
effect' _ WOOD SHINGLES ❑
Licens =a ' '5� Lic.Number '
oats 1- contractorOTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em 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
construct.alter,Improve,demolish,orrepalrany structure,prlortoits Issuance,also requlreathe BUILT-UP ROOF ❑
• applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions y
of the Contractor's License Law(Chapter 9(commencing with Section 7001 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
a civil penalty of not more than five hundred dollars($500).1:
❑I,as owner of the property,or my employees with wages as their solo compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes.
sions Cade:The Contractor's License Law does not apply to an owner of property who builds or WOODSHINGLES El
thereon,and who does such work himself or through Ms 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) ❑
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 Professions Code:The Contracture License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who bullus or improves thereon,and who contracts for such project.
with a contractor(s)licensed pursuant to the Contractors License Lew. PROVIDE MFGR.INSTALLATION SPECS.
E]I am exempt under Sec. ,B 6 P.C.for this reason {4 r
Owner Date APPLICATION DATE VAL 10 PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Building
as provltletl for by Section 3700 of the Labor Code,for the performance of the work for which this
permit Is IF. L�' t
El Seismic
1 haveva and end will maintain Worker's Compensation Insurance,as required by Section 3700 of / �/ I!
the Labor C for the performance of the work,for which this permit Is Issued.My Worker's
Compere n ns,; a rend tic n,,, ,are: ,�///,,�� p Total
carver / Policy No.'0 xe ^ 3a3 rOo'o ER%T AUTHORIZATION D E
CERTIFICATE O EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NA.❑ �
(This section need not be completed If the perm) for one hundred dollars($100)or less.)
I carli that in the performance of the work 1 hic this permit is issued.I shall not employ
any per n any manner so as to become a act to the Workers'Com ens.an Law of can- roofs shall be inspected prio o any roofing Material being
lornip installed. If a roof is installed without first obtainin an
Date Applicant 0,1rinspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this tificate of Exemption,you should become A ' ant understands and will comply with all non point
subject to the Workers'Compensation provisions the Labor Code,you must forthwith comply p y p
with such provisions or this permit shall be dee revoked. OU rce reg i atlOn S.
I certify that I have reed 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,end All troof5ov cin to be class" 'or Bette
hereby authorize representatives of this city to enter upon the above-mentioned property for In- ��
spection purposes. .L.
00,(We)agree to save,Indemnify and keep harmless the City of Cupertino egalnst Ilebllltlea.
judgments,costs and expenses which may In any way accrue against said City In consequence IGNATU OF APPLICANT DATE
of the granting of this permit.
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