R-4522 PERMIT .
APPLICATION FOR CITY OF CUPERTINO NUMBER R-
4522
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 oma
RESIDENTIAL--- COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
n YES ❑ If yes—I understand that a Class A
NAME C� roof assembly is required.
7� NO Initial I.C.B.O.#
ADDRESS
/C,� � y//� �-e EXISTING ROOF COVERING
PHONE
NUMBER OF EXISTING COVERINGS /
i
CONTRACTOR'S
NAME �� Q
TO BE REMOVED TO BE RETAINED
ADDRESS /�Fz ��e O TYPE OF ROOF COVERING
CITY&ZIP /� �7 EXISTING
PHONE o)ay/ BUILT-UP ROOF ❑
LICENSE
NUMBER 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 full force and
effect. 2]� WOOD SHINGLES{ �
License Class c.Number p" ® ❑
Date '�' ° convenor ��✓yg/�S�t�i OTHER(SPECIFY) ❑
OWNER-BUILDEFiCEaLARATION PROPOSED pyG
I hereby affirm that I am exempt from the Contractor's License Law for the following reason. �R�ll'zY
(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 theBUILT-UP ROOFv (Jf Gv� ❑-
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions ytl
of the Contractors License Lew(Chapter 9(commencing with Section]000)of Division 3 of the
Business and ProfessionsOf Code)or that he Is exempt therefrom and the basis for thea ant to ASPHALT SHINGLES ❑
exemption.Any violation ai Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty not more than five hundred donors($500).):gaWOOD SHAKES
❑
❑I,as owner oftheproperty,or to employees with wages as their sole compensation,will Profes-
sions
work,and he structure is not Intended ores not for sale(Sec.7044,Business and builds
or
improves
The Contractors License Lew does not apply to an owner of property who builds or WOOD SHINGLES
improves o thereon,n,ono who does such work offered
or through his own employees,Improvement
that ❑ /(
such Improvements are not Intended or ow etl for seer.I(however,the building of at he di fil
iesoto uildwithin year of for purpose
sthe 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 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 contractogs)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.or this reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of Perjury one of the following declaration:
❑I have and were maintain a Certificate of Consent to self-insure for Worker's Compensation, ZZ Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this 7
permit Is Issued. Seismic
I have and were maintain Worker's Compensation Insurance,as required by Section 3700 of
the Labor Co r the pedormenoe of the work for which this permit Is issued.My Worker's r (J �/Z�'J 0• Q(] Total
Comperes' n Insurance ner antl PoI' umbar e: //
Carrier � Policy Not6m, 4faLl-O PERMI AUTHORIZATION DATE
CERTIFICATE OF E MPTION FROM WORKERS'
COMPENS TION INSURANCE N.C.I]
(TMs section need not be completed if the permit is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which gs parmlt is Issued,I shall not employ
any person In error so es to become subject t rkers'compensation Laws o can- All roofs shall be inspected prior to any roofing material being
farm. installed. If a roof is installed without first obtaining an
Dais 1�Applicant v` inspection,I agree to remove all new materials for inspection.
subject
,Co EhTOVJ PkersCCompens ton parovlslones of iiL o°coati yoeu musafoinwitlhb amply Applicant understands and will comply with all non point
with such provisions or this permit shall ba deemed re o d. SOUr -regulations.
1 certify that I have read this application and state th he above Information is correct.I agree
to comply with all city and county ordinances and state laws relating to building conslructlon,an0 A roof coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property br in-
spection purposes. �j
(We)agree to save,indemnity and keep harmless the City of Cupertino agonal liabilities, r
judgments,costs and expenses which may In any way accrue against said City Inconsequence
of the granting of this permit. S ATUR OF 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