R 4750 APPLICATION FOR CITY OF CUPERTINO
NUs RR- 4750
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN DAVE OF PERMIT ISSUANCE OR
WI DANSS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
Zl 1 —' y RESIDENTIAL COMMERCIAL - OTHER
OWNER' r/� '— HAZARDOUS FIRE AREA
`� M VES ❑ If yes s I assembly
is req that a Class A
NAME 1 �'/ lllU�-�J� \VV/ A roots—I understand
n tyis required.
(� Q NO Initial I.C.B.O.If
ADDRESS '7' EXISTING ROOF COVERING
C_� -
PHONE NUMBER OF EXISTING COVERINGS
CONTR TOR'S
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS ci TYPE OF ROOF COVERING
CITY 8 ZIP
t ^ EXISTING
PHONE l ' BUILT-UP ROOF
LICENSE
i NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES ❑
7000)of Dlvielo of e B ase and Professions Cotle,and my license Is In full force and
effect.
WOOD SHINGLES ❑
License Cie � Llc.Number
Date contrect r OTHER (SPECIFY) ❑
blINER-BUILDER C ION PROPOSED
I hereby Tim that em exempt from the Contractor cones Law for the following r son.
(Sec.7031.5,Business and Professions Code: Any cl county which requires a permit to
construct,alter,Improve,demolish,or repair any structure, lot to its Issuance,also requires the BUILT-UP ROOF
• applicant lot each permit to Ills a signed statement that he I canoed pursuant to the provisions
of the Contractor's License Law(Chapter a(commencing wl on 7000)of Division 3 of the
Business and Professions Cotle)or that he Is exampt.aft e o anq the basis for the alleged ASPHALT SHINGLES ❑
exemption,Any violation at Section 7031.5 by any appi(cant a It subjects the applicant to
a civil penalty of not more than five hundred do 5 is I .
01,as owner of the property,or my empkryees th as their sole compensation,will do WOOD SHAKES f111 A I V R1 C:1the work,and the structure is not Intended or olle sale(Sec.7044,Business and Profes. P
alone Code.The Contractor's Liceno w apply to an owner of property who builds or WOOD SHINGLES 1:1Improves thereon,antl whodoeeeuo r or through his own employees,provided that APR s' 9
such Improvements ere not intend r for sale.It,however,the building or Improvement 19Qg
Is sold within one year of mmpMlo owner-builder will have the burden of proving that he did OTHER(SPECI 3LEAI
not build orImprove torr purpoe of„m e..
❑I,as owner of the property,a;m exclusively contracting with licensed contractors to construct I r 1 IItlU
the project(Sec.7044,Business and Profession Code;The Contractor's License Law does not PROVIDE I.C. .V.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 Contractors License Law, PROVIDE MFG R.INSTALLATION SPECS.
❑I am exempt under Sec. ,B a P.C.for this reason
Owner Data
WORKERS COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to self-insure for Workers Compensation, BUlldln
asprovidedis Is for by Section 370001 the Labor Code,for the performance of the work for which this 1 , /� g
permit is leeuatl. �--J\' vt` BISmic
❑ have and will maintain Worker's Compeneatlf Inhir hs,as required by Section 3700 of s
o the Labor Cotle,for the performance of the work 1 which ius ermd la lasuetl.My Wor '
Comp a n 1 suranc carr er en Iicy numbs re: ' Total
Gerrie Policy PERMIT AUTHORIZATION DATE
CERTIFI ATE EXEMPTION ROM WORKERS'
COMPENSATION INSURANCE N.C.I]
(This section need not be completed If the permit is for one hundred dollars is 100)or less.)
I certify that In the performance of the work for which this permit Is issued shall not employ
any persom in filly thinner so as to become ubject to the workers'Compensation Lawa of Cali- All roofs shall be inspected prior to any roofing material being
for a' installed. If a roof is installed without first obtaining an
Dare Appfl ant - inspection,I agree to remove all new materials for inspection.
NOTI TO APP CANT: If,atter making Mle Certlllcete of Exemption,you ehoultl become Applicant understands and will comply with all non point
Subject to he Workers'Compensation provisions of the Labor Cotle,you must forthwith comply PP P Y P
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 r00 coverings(to bess")C" rbetter.
hereby authorize representatives of this city to enter upon the above-mentloned property for In.
purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino o ttimn Ilabliltae,
• judgments,costs and expenses which may In any way accrue against said City n Consequence
of the granting of this permit. TIGNATURE OF APPLICANT DATE
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