R-4589 PERMIT R_ 4589
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
// (✓ RESIDENTIAL COMMERCIAL OTHER
OWNER'S I HAZARDOUS FIRE AREA
NAME��/� Y ❑ If yes—I untlerstand that a Class A
�✓✓� / y l ✓ f assembly Is required.
�+ / / NO Initial I.C.B.O.k
ADDRESS Z I JKlK l n( t�� X err 4 V'e EXISTING ROOF COVERING
PHONE 7 NUM R OF EXISTING COVERINGS I
CONTRACTO, S
LI r /\ TO BE REMOVED TO BE RETAINED
NAME / r J /'T
ADDRESS TYPE OF ROOF COVERING
CITY III ZIP %206 1;AW' /`7• Si1�/1r�Se EXISTING
PHONE YO s' SR� "'�� 3 z� BUILT-UP ROOF ❑
CENSE
NUMBER C'^ l _' — ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Cotle,and my license Is In full force and
effect _ WOOD SHINGLES El
License Class — Lia Number
Date qZS�� Conbeclo OTHER(SPECIFY) ElOWNER-BUILDER D uRAnoN PROPOSED
hereby affirm that I am exempt from the Contractor's License Lew for the following reason.
(Sec.]0315,Business and Professions Code: Any city or county which requires a permit to
corrultapplicant for such prove,ermit demoto file signed
or ed sta anystructure,Is licenor tose Issuance,to the
the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement nci g Is licensed pursuant to the pro of the
of the ss an dors license Law(Chapter h(commencing with Section 7000)of Division 3 of the
Business ptio and Professions Code)or that he Is exempt therefrom and the basis forhe the alleged ASPHALT SHINGLES ❑
exemption.Any violation of Section hundred
by any applicant for a permit subjects the applicant to
e civil penalty of not more than five hundred dollars( ): WOOD SHAKES
1,as owner of the property,or employees with
wages as their sole compensation,will do
the work,and the structure Is not intended or offered for sale(Sec.7044,Business and Profas.s� I
slons Code: The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑
Improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for sale.It,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.).
CD 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 contractors)licensed pursuant to the Contractor's License Law, PROVIDE MFGR.INSTALLATION SPECS.
I am exempt under Sac. .B&P.C.for this reason f
Owner Date - APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
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 Worker's Compensation, Bu
as provided for by Section 3700 of the Labor Cotle,for the performance of the work for which this
it Is
permabor Code, q C,,? Seismic
❑1 have and will maintain Workers Compensation Insurance,as required by Section 3700 of c A
the Labor Code,for the performance of the work r a which this permit is issued.My Worker'61 If—
Compensation � Total
' Insurance carrier and Policy number are: L��, 8
I
Carrier Policy No. I C6.,,,PE MLYAUTHORI Pt IAT
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This 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 this permit Is Issued I shall not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Call- All roo n shall be insPelcted4itl aW r oft at vial being
fornia. / installed. If a roof is installed witiolilit first obtaining an
Date ( 9 Applicant i C ��`�.,� inspection,I agree to remove all new materials for inspection.
NOTICE TO PPU ANT: If,after making this Certificate of Exemption,you should become Applicant understands and will I with all non point
subject to the Orkem'Compensation provisions of the Labor Code,you must forthwith comply PP comply Y P
with such provisions or this permit shalQbe deemed revoked. Source regulations.
I Cartity that I have read this application and state that the above Information is correct I agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof coverings to be class"C"or better. ,
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
sppurposes
(We)
(We)agree tos save,expenses
and keep harmless way the City a against
Cupertino against liabilities, i
judgments,costa and expenses which may in any way accrue against seed Ciry in consequence SIGNATURE OF APPLICANT DAT
of the Granting of itlia permit.
PRE-INSPECTION: PLYWOOD: IN-PROGRESS: l
INSP. DATE INSP. DATE INSP. DATE I/
TEAR OFF INSPECTION: BATTENS: - FINAL:
INSP. DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY I