R-4605 RMIT
APPLICATION FOR CITY oF.cuPERnrvo
NUMBER R— 4 6 p Jr
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (406)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
. 100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
ES/ ,/�L y�
6� 4 (f t �S e: S �" RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
�, ,/ t / YES ❑ If yes-I understand that a Class A
NAME /"/ �/ _ roof assembly is required.
''']�� NO Initial I.C.B.O.III
__/ C
ADDRESS A5) ! - �s �� $' 9r EXISTING ROOF COVERING
PHONE 71,2 — -S NUMBER OF EXISTING COVERINGS /
CONTRACT S
NAME Id-
O O r-,t /�C. TO BE REMOVED TO BE RETAINED
TYPE OF ROOF COVERING
ADDRESS ;7
clry a zip
S � ��f C 4h EXISTING
4'4L^� ,Jos � 7 5
PHONE -.:p 9_1� 7 BUILT-UP ROOF ❑
LICENSE
NUMBER /S'-g Q ASPHALT SHINGLES El7
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(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 Class C 9 Lie.Number
4 IPS ^ frs- tor _ r OTHER(SPECIFY) ElDaleBILD
OWNER-BUILDER DECLARATION PROPOSED
hereby ellthat em exempt from the Contractor's License Lew for the following reason. ,
(Sac 70315Bu,Business and Professions Code: Any city or county which requires a permit to
construct,alter,suImprove,to fildemolish,signed stireny mentrthat he prior to ISlicense issuance,alsorequirea the BUILT-UP ROOF ❑
applicant for such permit a file aChapt statement that he Is licensed pursuant to the provisions
. of the Contractors License Lew(Chapter 9(commencing with 7000)of Division 3 0l the
Business and Professions Code)or that he Is exempt therefromomSection endnd the bash for the scant to
ASPHALT SHINGLES
exemption.Any violation of than live 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500).):
E]1,as owner of the property,or my employees with"gas as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Protea-
sicns Code:The Contractor's License Lew does not apply to an owner of property who builds or WOOD SHINGLES ❑
Improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not intended or offered for sale.If,however,the building or improvement
IS Sold 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 Bele.).
I,as owner of the property,am exclusively contracting with licensed contractors to construct
the 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 contractor(s)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION q
I hereby affirm under penalty of perjury one of the following declaration: P A a„
❑I have and will maintain a Certificate of Consent to Self-insure for Worker's Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this t
permit is Issued. SEP ,2 Jr Seismic
❑ have and will themainsif Worker's Compensation which this as required by Section Worker700 ofs
i/
the Labor Cotle,for the performance of the work for which This permit Is issued.My Workers Cl995 qp Total
-the
Insurance terrier and Policy number are:
li
Carder Policy No. PEFlMITAUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need not be completed if the permit Is for one hundred dollars($100)or less.)
I certify that In the performance of the work for which this permit Is Issued,I shall not employ
any person In any manner so as to become aypjecl t Ike l ao inno mroywa of Cali- All roof.^,shall a inspected prior to any roofing ma ria being
fornla. i/' /Y- / installed. If a roof is installed without first obtaining an
Date 9^ods^ qS Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Ex ption,you Shot atoms Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Co a,you most forthwith comply PP P Y P
with such provisions or this permit shallibe 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 class' "or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in
hereby
purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against Ilabilitiee,
. judgments,costs and expenses which may In any way accrue against said City in consequence `SIGNATURE OF APPLICANT DATE
of the granting of this permit.
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 COPY