R 474910
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PERMIT
NUMBER R- 47 4 9
APPLICATION FOR CITY OF CUPERTINO .
INSPECTION DIVISION PERMIT EXPIRATION '
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 700 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
1t
RESIDENTIAL COMMERCIAL OTHER
OWNER' -
HAZARDOUS FIRE AREA
'
❑ thatClass A
NAME
roof assembly is rreega
NO ❑ Initial I.C.B.O. It
/�
EXISTING ROOF COVERING
ADDRESS C'U
t
PHONE
NUMBER OF EXISTING COVERINGS I
CONTRA OR'S
.
NAME
TO BE REMOVED - TO BE RETAINED
ADDRESS O
h-- TYPE OF ROOF COVERING
CITY &ZIP
EXISTING
-
PHONE
BUILT-UP ROOF ❑
LICENSE
NUMBER
ASPHALTSHINGLES ❑
L NEED NTRACTORS DECLARATION
hereby ithat em licensed under provisions of Chapter S (commencing with Section
700 0) of Division
on 3 0l the Buelneee Profeaslone Code, license le In lull Toros
WOOD SHAKES /
end entl my and
affect. Q�l
WOOD SHINGLES ❑ dam/
Lice se Cle e Lie. Numbs
. b
OTHER (SPECIFY) ❑
Date convector
21AER-BUILDER DffLikRATION
I hereby affirm that I m exempt from the Contractor's License Law for the following rasa n.
PROPOSED
(Sac. 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 the
BUILT-UP ROOF ❑
applicant for such permit to file 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 of the
Business and Professions Code) or that he Is exempt therefrom and the basis for the alleged
ASPHALT SHINGLES ❑ '� ,4Na�
exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
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a civil penalty of not more than five hundred dollars ($500)J:
E] 1, as owner of the property, or my employees with wages as their sole compensation, will do
Sv
WOOD SHAKES
the work, and the structure Is not Intended or offered for sale (See. 7044, Business and Profile.
alone Code: The Contractor's License Law does not apply to an owner of property who builds or
Improves thereon, and who does such work himself or through his own employees, provltletl that
such Improvements are not intended or offered for sale. If, however, the building or Improvement
WOOD SHINGLES ❑
lase to 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, em exclusively contracting with licensed contractors to construct
the project (Sec. 7044, Business and Professions Code: The Contractor's License Lew 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 contractor(.) licensed pursuant to the Contractor's License Law.
[II am exempt under Sec. ,B & P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner Date
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 sell -Insure for Worker's Compensation,
as provided for by Section 3700 of the Labor Cotlafor the performance of the work for which this
1 1 ^
I 1 y''/
f r
Building
g�-`�
permit is Issued.✓111KAr
❑ have and will Worker's Cc if Iheuranca, ee requlretl by Section 3700 0l
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�[f_, L 1( l
$elSrnlC x :?L)
the performance
_the Labor Cade, kr the performance cf the work welch thls permit la Issued. My Worker's
Y7% J
Cam Insure a arrlsr a Ilcy numbs to: .�1 I i- (�
Total s -S
r (
car Policy N.\JAI(
PERMITAUTHORIZATION
DATE
CERTIFICATE OF EXEMPTIO flOM WORKERS'
J5
4 r G�
COMPENSATION INSURANCE N.C.p
(This section need not be completed If the is for one hundred dollars less.)
permit ($100) or
I In
O.T
l.�
/ 7
certify het the padormence al the work for welch thio permit a Issued, shell not employ
All roofs shall be inspected prior to any roofing material being
o In any m nner eo ea to become eu the work.! ompe aatmn Lewa of call-
,anyaIpee�s�T�APPONT;
lot
installed. If a roof is installed without first obtaining an
Datepplleant
inspection, I agree to remove all new materials for inspection.
Applicant understands and will c non clot
PP f�p
NOTter makingthis Certificate o xemption, you should bet me
subject the Works Compensation provisions of the Labor Code, you moat forthwith comply
with such provisions or this permit shation deemed revoked.
h or
state that the above Information Is Correa. agree
certify that have read thisapplicationordinances laws to
to
SOUTCe regulations. ❑ IIS II��
All roof tob I
ruponhelating
hereby uthorzerepend secountyordinancesandetete
bovis-bentiogconatpertlyfantl
hereby authorize representatives of this city to enter upon the shove -mentioned property for any
ep(We) purposes.Rom
coverings
�/ r
(We) agree sive, Indemnify and keep harmless the Cupertino
s a ai y Inagainst ,liabilities,
judgments c9 is entl Pxpeneee which may In any way accrue against said City In cones
s
of the rantin of tela strait. � a
I TU E OF AP LI ANT DAT
PRE -INSPECTION:
PLYWOOD:
IN&W ^VECTION
itis LUNO
DEPARTMENT
INSP. DATE
INSP. bATE'U'-' ,i
INSP.
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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