R 4562 APPLICATION FOR /J 1\` CITY OF CUPERTINO NUMa R R- 4562 ,
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
BUILDING ADDRESS
100 DAYS FROM IASTCALLED INSPECTION.
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
y, I —I YES ❑ If yes-roof as emblyunderstand required. Class A
NAME v C-W�L I(vA1 NO roof assembly is requiretlt
`^ n ❑ Initial I.C.B.O.7t
ADDRESS 1 I (r ' e EXISTING F ING
PHONE
—Liol (0
(, NUMBER OF EXISTING COVERINGS
CONTR CTOR'S
•ori�/+ TO BE REMOVED TO BE RETAINED
NAME J 1 lu.
ADDRESS L TYPE OF ROOF'COVERING
CITY&ZIP M tom -
EXISTING �
PHONE(An CI(g9-(JIO
BUILT-UP ROOF ,
CENSE
NUMBER
C; ASPHALT SHINGLES %/❑_�
LICENSED CONTRACTORS DECLARATION \ 1 I
I hereby affirm that I am licensed under provisions of Chapter 0(commencing with Section WOOD SHAKES r'
7000)0f Division 3 of the Business and Professions Code,and my license is In full force and \ I❑ I
engin. WOOD SHINGLES j❑!
r^/
License Class"_ Llc.Number � r � )� k � t
(p /OTHER(SPECIFY)
Data Conran i % ❑ .
OWNER-BUILDER DECLARATION �~/ PROPOSED
I hereby allirm that I am exempt from the Contractor's License Law for the following aeon. //
(Sac.7031.5,Business and Professions Code: Any city or county whldh requires a permit to
construct,alter,Improve,demolish,or repair any structure,prior to its Issuance,also requlresthe /\ BUILT-UP ROOF ❑
applicant for ouch permit to IIIe a signed statement 1101 he Is licensed pursuant 16 the provisions
• of the Contractor's License bde( or thar0(pOmmencing with Section In's b of DIviAInnthe h le the pp // /
ex emeea and violation of Sectio or 31.5 b fare applicant
therefrom and the tesla a the alleged —�, ASPHALT SHINGLES A�/
exemption.pen.Anyf violation more
al Sanlcn hundr by shy appllcont lode permit eublecta the applicant td
a civil penalty of not mole than five hundred dollars(550P)J: t
❑1,as owner of the propeity,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for'sale(Sec.7044,Bualnaes and Profen
sions Code:The Contractor's License Law does lint apply to On owner of property who builds or WOOD SHINGLES
Improves thereon,and who does Such work himself or through his own empioyeee,provided that ❑
such Improvements ere not Intended or offered for said.ll,-however,the building or Improvement �
Is sold within one year of completion,the ownerbuildei will have the burden of proving that he did ❑ .�M a�•
not build or Improve for purpose of sale.)!" OTHER(SPECIFY) Al " " " "—
_A"
ely c�cling with licensed correctors to construct
the prolect(Sec.7044,Business and Professions Code:The Contractors 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 contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sac. ,B a P.C.for the reason
Owner Date
WORKERS COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: r-D f�
01 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, L
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
I Building s�
pah lead. JUN 12 1996 Seismic
have and will maintain Worker's Compensation Insurance,as required by Section 370001
ma bor Code,for the performance of the work for which this permit le Issued.My Worker's
Companeetio Insurance carr and Policy number are: 1! ? > Total
• Carrie Policy No.nn IJlOa.J 77 " "'PERMIT AU T'ORIZATION DATE
CERTIFICA O XEMPTION FROM WORKERS'
COM INSURANCE N.C.
the per O
(This section need not be completed If the permit Is for one hundred dollars(51 00)or leas.) CfGYs
1 certify that In the performance of the work for which this permit Is Issued,I shall not amplW
any person In any manner so as to become subject to the Workare'Compensation Laws of Cal All roofs shall be inspected prior to any roofing material being
lentils, installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
subjecctloo Etnee Worrkers'Compensation provisionso meL born Code yolu must forthwlitlhbcomply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. source regulations.
I certify 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 cla "C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for Im
spectlon purposes. ^1
p(We)agree to save,Indemnify and keep harmless the City of Cupertino against Ilablllllos,
. allhe raft`tiof tand his expenses which may in any way accrue against said City 4n consequence NATURE PPLIC DATEgranng
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE INSP. DATE INSP. DATE
a NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY