R-4645•
•
OFFICE COPY
R R- 4645.
APPLICATION FOR CITY OF CUPERTINO rNUMB
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 .PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
' 180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
0 Len
RESIDENTIl COMMERCIAL OTHER
OWNERS
HAZARDOUS FIRE AREA
A
SL1
YES Cl If yes - I understand that a Class A
NAME i�i/1 fY
roof assembly is required.
NO Initial I.C.B.O. g
//// �
���� � C.4
EXISTING ROOF COVERING
ADDRESS /`/'e ih ,P
/
/S
NUMBER OF EXISTING COVERING§
PHONE
' /
CONTRACTOR'S '.
/ O ,/>'dwi Nom-
NAME h/i1 Ac //�l
TO BE REMOVED v TO BE RETAINED
f-�
TYPE OF ROOF COVERING
ADOREss�+ v n��i
CITY a ZIP 5"�S�_,(�-4'c t/� PA, z 7'S l'
EXISTING
PHONE ��� '� 2hg�„Z�%
BUILT-UP ROOF ❑
LICENSE
NUMBER / /
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 lull force and
effect. N•`7 /
License Class Lic. Number 9x✓
WOOD SHINGLES ❑
/)-
Date �/x2—S' ContractorJil Z_
OTHER (SPECIFY) ElOWNER-BUILDER
DECLARATIO
PROPOSED
I hereby affirm that 1 am exempt from the Contractor's License Law for the following mill
(Sec. 7031.5, Business and Professions Code: Any city or county which require. 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 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 ❑
exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a Gill penalty of not more than five hundred dollars ($500).):
WOOD SHAKES
I, as owner of the property, or my employees with wages as their sole compensation, will do
the work, and the structure is not intended or offered for sale (Sac. 7044, Business and Profes-
sions Code: The Commences License Law does not apply to an owner of property he 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
I. sold within one year of completion, the owner-bullder will have the burden of proving that he did
OTHER (SPECIFY)❑
not build or Improve for purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with licensed contractor. to construct
the project (Sec. 7044, Business and Prolessions Code: 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.
L]I am exempt under Sec. ,B B P. C. for this reason
Owner Date
APPLICATION DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
her fflrm under penalty of perjury one of the following declaration:
PI
eve 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
permit Is Issued.
-
i1
❑ I have and will maintain Workers Compensation Insurance, as required by Section 370001
1 have
the Labor Code, for the performance of the work for which this permit Is Issued. My Workers
'Compensatio�n[
oA�
Seismic
Ins�u/rplice oarrler and Pol number are:
{b�
`� �AF
VV [r5i
Total
'
ORIZATION
DATE
Carrier S/.L TP Policy No,-� :'��Y1=N��R
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.]
1(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 subject to the Workers' Compensation Laws of Cell.
All roofs shall be inspected prior to any roofing material being
prnia.installed.
If a roof is installed without first obtaining an
Data Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE ��)PPUANT:subject isions you
Applicant understands and will comply with all non point
to the Workers' Compefnsation provafter
of theiLabor Code, must forthwlithbecome comply
with such provisions or this permit malt be deemed revoked.
source regulations.
I certlfythat I have read this application and state thatme above Information Is correct. ) agree
to comply with all city and county ordinance and state laws relating to building construction, and
All roof coverings to be class "C" or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes.
C
(We) agree m save, Indemnity and keep harmless the City of Cupertino against liabilities,
judgments, coats and expenses which may in any way accrue against said City In consequence
SI APPL A A TE
of the granting of this permit.
n.
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