R 492811
i
OFFICE COPY
PERMITq. 4 9 2
APPLICATION FOR CITY of CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
U/]
.
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
0—�
if HAZARDOUS FIRE AREA
YES ❑ If yes — I understand that a Class A
NAME
root assemGy is required. -
NO Cl Initial I.C.B.O. M
/� �p
t' 1
EXISTING ROOF COVERING
ADDRESS 1
NUMBER OF EXISTING COVERINGS
'jam
0
PHONE lJ���
TO BE REMOVED '�"t' TO BE RETAINED
CONTRACT '
I rC (I
NAME
ADDRES
I I
TYPE OF ROOF COVERING
CITY&ZI -
,VIJEXISTING
PHONE- � �� r
- .
❑
BUILT-UP ROOFLICENSE
NUMBER ���
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B (commencing with Section
WOOD SHAKES
yp
7000) of Division 3 of the Business and Professions Code, and my license is In full force and
effect —^s7�
�
WOOD SHINGLES ❑
License Claes ✓q Lie. Number SL�1
7-
OTHER (SPECIFY) ElOWNEm-SUILDEBUILDE
Date
EC AR N
1 hereby affirm net I em exempt from the I L cense Law for the following reason.
PROPOSED
i and ny city
Cod ny city or county which requires a permit to
(Sec. 70315, Busineindented
demolish,
construct, atter, improfile es, or repaired t core, fmortoliven ha Issuance, also requires the
or rep
for such pefile a sig qd n5teme hat Is licensed pursuant to the provisions
BUILT-UP ROOF ❑
of the
of the Co LiLow ((Ch ter In (m Ing with 7000) of Division 3 at the
g the
ss and omSectfonand
t n x ttherefrom and the basis for the alleged
end Profesocoon
ASPHALT SHINGLES ❑
exemption. 7t
exemption. An mien ]0in 6 p Icentfor a permit subjects the applicant to
of
of '
a civil , penalty of not en five m o is (h wage:
❑ I, of tppert or oea with wages compensation,sandPr111
WOOD SHAKES
(as See,their 44,
the work, entl the
k and the e s.
ended for eels Business and Probs-
ores ow
oht Law not n owner at
Impr Code: The Con or' nae Lew does not apply to an owner of property who builds or
Improves thereon, an. tech work himself or Through els own employees, provided Net
WOOD SHINGLES
❑Is
co Improvementsatended orofferedbrsale.If,ill however, the
n Improvement
-
within one year olcompletion, enbuilding of pros
owner -builder wlll have the burdenolprovingthat nedid
OTHER(SPECIFY) ❑
notbuatsalthe
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 contractors) licensed pursuant to the Contractors License Law,
❑ 1 am exempt under Sec. ,B & P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner Deb
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION
PERMIT FEE
I hereby affirm under penalty of perlury one of the following declaration:
a (S
❑ I have and will maintain a Certificate of Consent to sell -Insure for Worker's Compenseilon,
/IQ s
Buildin
as provided for by Section 3700 of the Labor Coda, for the performance of the work for which this
permit is issued. /�
"have and will maintain Workers Compensation Insurance, as required by Section 3]00 Chi
{Y(/ �
t5 Jgg6
^
/y�}
I Il `� 11]
Seismic
of
the Labor Coda, for the performance of the work for which this is issued. My Workers
y
lJh
-
permit
CompensatlonlIIna.�{�r—e�nce trier Policy nu bar are:
`
fl)-
Total
1p �� +
Carrier
Policy
PERMITRIxAUTHOION
DATE
CERTIFICATEEXEMPTION FROM WORKERS'
COMPENSATION
SATION INSURANCE N.C.I]
(This section need not be completed If the permit Is for o note s ($100) or lase.)
I certify that In the performance of the work for which er uetl, 1 shall not employ
All too s shall be Inspected prior to any rooting materia being
any parson In any manner so he to become subject t comptnsallon Laws of call-
fornia,
installed. If a roof is installed without first obtaining an
Dai. Applicant.
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: II, after m irn s Icate of Exemption, you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
Applicant understands and wi m
pp ply with all non point
with such provisions or this permit shall be deemed revoked.
Source regulation
I certify that 1 have read this application and state that the above Information is correct. I agree
to comply with all city and county ordinances and stele laws relating to building construction, and
All roof cove ' C" or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes.
(We) agree to save, Indemnify and keep harmless the City of Cupertino against liabilities,
a
judgments, costa and expenses which may In any way accrue against said City In consequence
of the granting of this permit.
SIGNATU OF AP (CANT DAT
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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY