R-4525 PERMIT R_
APPLICATION FOR clTv of CUPERTINO NUMBER 4525
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS - 1/,.',O
ru ' l_ RESIDENTIAL ` COMMERCIAL OTHER
OWNER'S k 00 re HAZARDOUS FIRE AREA
I►/�y,,` YES ❑ It yes—I understand that a Class A
NAME ( 1 ' roof assembly is required.
NO ❑ Initial I.C.B.O.q
ADDRESS C EXISTING ROOF VERING
PHOaT � D NUMBER OF EXISTING OVERINGS
CONTR S
NAME TO BE REMOVED TO BE RETAINED
ADDRESS I TYPE OF ROOF COVERING
CITY&ZIP I �J .
EXISTING
PHONE BUILT-UP ROOF
LICEN
NUMB ASPHALT SHINGLES ❑
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
affect' (/ WOOD SHINGLES
Licen a Class v Lie.Numbar ❑
t OTHER(SPECIFY) ❑
Date Contractor
-*4RATI01 PROPOSED
I hereby affirm that I em xempt from the Contractors License Law for the follming reaso
p
(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 10 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 Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES Q
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to ..S
a civil penalty of not more than five hundred dollars($5001 O�/ �❑B
7]1,as owner of the property,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,Business and Proles- n
sions Code: The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES �1Ty yL51
improves thereon,and who does such work himself or through his own employees,provided that p
such Improvements are not intended or offered for sale.It,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) ur`❑
not build or Improve for purpose of sale.). /
01,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Cede: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 Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PE E
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
-11 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 Cotle,for the performance of the work for which this
permit is issued. /
❑ qd
���f�,rcao
and Worker's Compensatl n Insurance,as required by Section 3700 of Seismic
the L �ennca of the work or which this permit is Issued.My Worker's Total
'en Policy numb are: �/�y�� I t {���I��ZS
.PolicyyJJNoo..�I ( PERMIT AUTHORIZATION DAT
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.p
(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 4amensos'to b me eu t to tho Workers'Companseli ws of all- All r00}^ I 1 pBCte Pfl p Y f g erl being
mrniaI installed. If a roof is installs wi ou rst t ng anppl n1. inspection,I agree to removiafo inspection.
OTICE after making this Certificate of Exemption,you should b come Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith c moy PP P Y P
with such provisions or this permit shalCbe deemed revoked. source regulations.
I certify that I have read this application and state that the above information Is correct.)agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof coverings t be ss"C or better.
hereby authorise representatives of this city to enter upon the above-mentioned property for in.spection purposes. /1 9 CII ^
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, tA Ah
ofthe grantingcosts
of his perrm texpenses which may In any way aurae against seitl City in consequence SIGNATURE OF APPLICANT DA
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