R 4609 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBERR_ 46 0 9
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
RESIDENTIAL COMMERCIAL OTHER
Ow HAZARDOUS FIRE AREA
C YES [:1IF yes—I understand that a Claw A
NA E J� Mf.,ne(/L root assembly is required
NO tial LC.B.O.N
ADDRE EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
TO BE REMOVED TOROOF BE RETAINED
ARF
NAME �Q' MO
ADDRESS o' ^
COVERING
PHONE— 2X3411I BUILT-UP ROOF ❑
LICENSE
NUMBER 414 f f ALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 9(commencing with Section AKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and ��..
effect. p WC70D SHINGLES
License Class 3 1 LIc.Number
Data Contractor
OTHER(SPECIFY) ❑
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
construct,alter,Improve,demolish,or repair any structure,prior to its Issuance,also requires theBUILT-UP ROOF Elapplicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
. of the Contractors License Law(Chapter S(commencing with Section 7000)of Division 3 of the e
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 lora permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500).):
p1,05 owner of the property,or my employees with wages as their sola compensatlon,will do WOOD SHAKES ❑
the work,and the structure Is not intended or offered for sale(Sec.7044,Business and Proles-
sions Improvoda:TheConlwhod essucLicenshLaw workhidoes not orthro through o an owner
ployerrywho rovide that WOOD SHINGLES
Improves thereon,and who does work offered
or through his own employees,Improvement that ❑
such Improvements are not Intended or offeretl for sale.If,however,the building or Improvement
Is ac to within one year of completion,the owner-bullder will have the burden of Proving that he did OTHER(SPECIFY)
not build or Improve for purpose of sale.).
❑I,as owner at the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Coca:The Contractors License Law does not PROVIDE I.C.B.O.REPORT N
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractors)licensed pursuant to the Contractors License taw. PROVIDE MFGR.INSTALLATION SPECS.
❑1 em exempt under Sec. ,B 6 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
Iher allirm under penalty of perjury one of the following declaration: (p p
eve and will maintain a Certificate of Consent to self-insure for Workers W Compensation, Buildin
e provided for by Section 3700 of the Labor Code,for the performance of the work for which this fd '
permit Is Issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of �T 1019 Seismic
the Labor Cotle,for the performance of the work for which this permit Is issued.My Warkeran/ r$ ��
Compensation Insure77ce carrier and Policy4number are: 11.. n Gr 9s tr Total
Carrier dNi Policy Na. 3SbS'�-7� PERN)IT)AUTHORIZATION DATE
CERTIFICATE OF EPTION FROM WORKERS'
COMPENSA ION INSURANCE N.C.D
(This section need not be completed If the permit Is for one hundred dollars($100)or less.) Q O
I certify that In the performance of the work for which this permit Is issued,I shall not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Cali- All roofs shall be inspected prior to any roofing ma erial being
forma. - installed. If a roof is installed without first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
NT CE TO APPLCANT, If,after became
subject t.the Workerls'Compensation provisionls o ths BhelLLabor Cod.,rtifcate at yolu must bnhwlltlh comply Applicant understands and will comply with all non point
with such provlslons or this permit shalgbe deemed revoked. Source regulations.
I certify that I have read this application and state that the above Information is correct.)agree
to comply with all city and county oromances and state laws relating to bulltling construction,and All roof coverings to be c "C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
ap(We) purposes. M "
(We)agree to save,expenses
and keep y I harmless the City of Cupertino against IIebII.....
• of the gran costs and expenses which meY In any way accrue against said Clry Inconsequence
of the granting of this permit GNA RE OFA PLIC T AT
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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