R 4859•
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R_ 4859
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 150 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
Ir
II
RESIDENTIAL COMMERCIAL OTHER
OWNER'
HAZARDOUS FIRE AREA
YES ❑ If yes — I understand that a Class A
NAME
roof assembly is required.
NO ❑ InI5a1 I.C.B.O. #
EXISTING ROOF COVERING
y�i
ADDRESS
PHONE y "
NUMBER OF EXISTING COVERINGS I
I
CONTRACTORS
NAM
TO BE REMOVED TO BE RETAINED
ADDRESS vl
_
TYPE OF ROOF COVERING
CITY 8 ZIP
EXISTING
�lq`
PHONE l�
BUILT-UP ROOF ❑
LICENSE
2
NUMBER
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em Ilcensed under provisions of Chapter 8 (commencing with Section
WOOD SHAKES
7000) of Division 3 of th Bu ass antl Professions 'Cope, ntl my license Is In lull force and
effect. U j -7aoD
WOOD SHINGLES ❑
Lice ea CI ee Lie. Numoer l C�C�
r
OTHER �`
Date contmclo
(SPECIFY) ❑
NER-BUILDER DECLARATION
hereby Affirm that exempt from the Contractor's Lew Mr the following reason.
PROPOSED 'JUN 26 1996
es permit to
(Sec. 7031.5, Business and or cotta
Code: Any city or county which requires
construct, alter. improve, tlamollan, ormpalren lruclure, prior to Its Issuance, also requires the
demolish, or lap a
applicant for ouch permit to file a signed state that he Is Ilcensed pursuant to the Provisions
BUILT-UP ROOF n�r 11
Ur wirr Cri t INN
of the Contractor's License Lew (Chapter a (cc Ging with Section 7000) of Division 3 of the
0l r
Business and Professions Code) or that he I9ax pt -therefrom and the basis for the alleged
ASPHALT SHINGLES �_
exemption. Any violation of Section 7031.5 ppy'llnye ic5nt for a permit subjects the applicant to
a civil penalty of not more thea five h d4d doll. ) ):
❑ I, as owner of the property, oc� pl w e as their sole compensation, will do
WOOD SHAKES ❑
the work, and the structure is not Intent or a sale (Sec. 7044, Business and Proles -
alone Cotle: The Conlrect License L apply to an owner of property who builds or
WOOD SHINGLES ❑
Improves thereon, andp does sue m elf or through his own employees, provided that
such Improvements ere of iron d red for eels. If, however, the building or Improvement
laeoltlwithinoneyeerof ml owner-bulltlerwlllhevelheburdenolprovinpihelhetlid
OTHER (SPECIFY) ❑
not bulltl or Improve for p se ale.).
❑I, es owner of leap per �m exclusively contracting with licensed contractors to construct
me project (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 contractors) licensed pursuant to the Contractor's License Law,
E]I am exempt under Sec. ,B 8 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:
❑ 1 have and will maintain a Certificate of Consent to self -Insure for Worker's Compensation,
Section
Building �4./
as provided 3700 of the Labor Code, for the performance of the work for which this
p r
permit Is Issued.
❑ I have and will Worker's Compensation Insurance, by
(J�p
�\W�J
$eISm C
c
as required
d. My a of
the Labor Code, for the penormence of the wor for which /�In permit is Issued. My We eYe
the Perform!
Co ti non en acarrl en Poltoy numb rare:..{ 11
I
Total
Ce12
PalIcyNo.
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF E%EMP ION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed if the permit Is for one hundred dollars (5100) or less.)
I certify that In the performance of the work for which this permit Is Issued, 1 shall not employ
All roofs shall be inspected prior to any roofing material being
any person In any manner so as to become subject to the Workers' Compensation Laws of Ceti.
fornla,
installed. If a roof is installed without first obtaining an
Dale Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: II, 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 cos
pP ply with all non point
with such provisions or this permit shalpbe deemed revoked.
Source regulations.
lecorrect. lagree
certify that I have read thisapplicationordinancandamtstelttheebOve Information tobuilding
city and county of
to ordinances and este laws and
abo to
All roof coverings to be cies "C" better.
hel
hereby authorize this above-mentioned t,
d property
hereby authorize representelivea of this city to enter upon the above-mentioned property kr In.
�� I to
Lq(�
specdon purposes.
r
(We) agree to save, Indemnity and keep harmless the Cory of Cupertino against liabilities,
judgments, costs and expenses which may In any way accrue against said CIry In consequence
of the granting of this permit.
SIGNATURE OF APPLIC UATIE
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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPV