R 4814 PERMIT R_ 4 814
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMITEXPIRATION
REROOF PERMIT (408)777-9228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN ISo DAYS OF PERMIT ISSUANCE OR
' - 180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS 1
1 G/ (r4t RESIDENTIAL COMMERCIAL OTHER
OWNER'S- - HAZARDOUS FIRE AREA
�• C-/->✓L VES [:] IFyes (understand thatClass
NAME t Y�4 Ch��. roof assembly is required..
- NOif, Initial I.C.B.O.a
ADDRESS J I .3 7 D4 r-"tl Anti lblr( EXISTING ROOF COVERING
PHONE 10
S .3•� / NUMBER OF EXISTING COVERINGS 2.
CONTRACTOR' /(
NAME lh�l (,Bre TO BE REMOVED TO BE RETAINED
f' CIT
ADDRESS 2-4 Q��� � �9 �Z TYPE OF ROOF COVERING
n
EXISTING
x PHONE `, 0993 BUILT-UP ROOFLICENSE
,,,,,,......,❑!!!.
NUMBER 2,e>57 7 ASPHALT SHINGLES gl,
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 em licensed under provisions of Chapter g(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect. WOOD SHINGLES ❑
License Claes Cr L Lic.Number
Date contractorJ OTHER(SPECIFY) ❑
OWNER-BUILDER DE R TIO PROPOSED
I hereby affirm that 1 am exempt from the Contractor's License Lew 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 the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
• of the ss and Contractors License Lew(Chaplet S(comm In yfl h Section the b of for the 3 of the
exemption.
x
Business entl violation of Code)or that he Is axe from and the Beale for the applicant
to ASPHALT SHINGLES
acivilpon.Anyvlolt ore of Section hundr by an y$ ani for epermit subjects meapplicant to
a civil penalty of not more than five huntlredtlgllar ).l:
❑I,asowneroftfoproperty,o,my'9mpl yoga with -a their sole compensation,will do WOOD SHAKES ❑
the work,end the structure Is.nolmends Q B(Sec.7044,Business and Profes-
sions Code;The Contrec a neebBWC s o.p" agawnerofpropertywhobuildsor WOOD SHINGLES
Improves thereon,an as as ch work I se u Mils own employees,provided that El
improvements ere no rit0.n odor r .11rhowever,the building or Improvement
laacldwithln oneyaarof sr Plate 't r•bpl11 r will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve br r o e.
❑I,as no of the prop ,gm b usively contracting with licensed contractors to construct
the project(Sec.7044,Busing and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an ownerof property who ulids or Improves thereon,and who contracts for such projects
with a contractors)licensed pursuant to the Contractors License Law. PROVIDE MFGR. INSTALLATION SPECS.
❑I am exempt under Sec. ,B&P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
1 hereby affirm under penally of perjury one of the following declaration: "s U
[:11 have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, BUlldln
277
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this AR .1 4 g
permit Is Issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of�� Ons Seismic
LCV
the Labor Cotle,for the performance of the work for which this permit Is laeuetl.My Worker's / VI" 6 Total
Compensation{pour@nca car entl Policy n er are: 22� �9.2�, L,Vr.-k,,- R`'w'
Carrier - ,*L ll7 Policy No. �2&Z6; 1_ PERIV1 AUTHORIZATION DATE
CERTIFICATE OF EXEN'PrON FROM WORKERS'
,k COMPENSATION INSURANCE N.C.I]
(This section need not be completed If the permit Is for one hundred dollars(5700)or less.) �'
I C U 6
I certify that In the performance of the work for which this permit Is laeuetl,I shall not employ 1iV
any person in any manner ea as to become subject to the workers'Compensation Laws of cot- All roofs shall be inspected prior to any roofing material being
fornla. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply 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 v rings to be..�000lass"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
/ ��
hereby
purposes, / C♦T/,//
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
judgments,coats and expenses which may In any way accrue against said City in consequence
• of the granting of this permit. SIGN, D —
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