R 4762 PERMIT R_ 4 7 6 2:::]
APPLICATION FOR CITY OF CUPERTINO NUMBER
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
RESIDENTIALy COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes-I understand that a Class A
NAME �`/! roof assembly is required.
NO ❑ Initial I.C.B.O.#
ADDRESS t'.J EXISTING ROOF COVERING
PHONE
_ NUMBER OF EXISTING COVERINGS Z
CONTRACTOR'S 1
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS TYPE OF ROOF COVERING
CITY B ZIP
EXISTING
PHONE 7O 7 BUILT-UP ROOF ❑
LICENSE
NUMBER G ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter a Scommencing with Section WOOD SHAKES 1-17000)of Division 3 of the Business and Profeaeiono Code,antl y Iconse Is In lull force and
effect. _ WOOD SHINGLES 1:1License Close
Lic.Number
Date contractor OTHER(SPECIFY) 4�A
OWNER-BUILDERDECLARATION PROPOSED AIOR I
I hereby affirm that I em exempt from the Contractor's License Law or L5
(Sec.7031,5,Business and Professions Cotle: Any city or county whit ulres a permit to „r t/ Ap
construct,alter,Improve,demolish,or repair any structure,pric Its Is e,also requires the BUILT-UP ROOF'Y U 6
applicant for such permit to file a signs of on that he Iff I en I$ quant to the provisions h
of the Contractor',License Lew(Chapter B(commancing[wit Sec on 000)of Division 3 of the Lrr
Business and Professions Code)or Ih°I he i,exempt tnarelr of a basis for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any app] t I It bjects the applicant to
e civil penalty of not more than live hundred doliars,(E d; WOOD SHAKES
❑I,as owner olihepropertgormy plo see with Is compensation,will do ❑
the work,and
the structure 19 not Into er o ared for ( 44,Business and Proles•
slons Code:The Conractoes License opt t to n her of property who builds or WOOD SHINGLES
Improves thereon,and who does such work I - rougl�,h8 own employee,,provided that El
ch Improvements are not Intended or she 16.hdwaver.the building or Improvement
Is sold within one year of completion,the ow will tieve the burden of proving that he did OTHER(SPECIFY) Elnot build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contr°dina with licensed contractors to construct
the project(Sec.7044,Business and Professions 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 contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for this reason
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 malntain a Certificate of Consent to self-Insure for Worker's Compensation, Building
as provided lot by Section 3700 of the Labor Code,for the performance of the work for which this g
permit Is lasuatl.
❑I neve maintain :kers Compensation Insurance,as required by Section Worker's of T+� ] ` q�v I $615mIC
iia Leber tle,for the ante of ih rk for Ich this permit is leauetl.My Worker's M`f;1Jl
Compens ion Incur er entl PoIImbar e: 9 Total
Carrier Policy PERMIT AUTHORIZATION
CERTIFICATE OFMPTION FROM WORKERS'
COMPENOnIINSUR N.C.p(TMs,action need not be completetl Il the ptlratl dollar°(E100)or leas.) KilI certify that in the performance of the work ft I leau I shall not amoptoyany person In ny manner so as to become sublom eatlon Laws of Celh All roofs Shall b IDS clad prior to any r offing matrlfll b
terns' 1/ installed. If a roof is installed without first obtaining an
Dale _/+ ✓� �gpplicent inspection,I agree to remove all new materials for inspection.
NOTICt subject to theOWorrkere'Compensation °rovlalane°o/ehelLeb. Iso 1 a palm ei foinwilin�ommO Applic t understands and will comply with all non point
with such provisions or this ermit shel�be deamatl revoke y py Sour re latlons.
I certify that I have read this application and state that ih ova Information le correct.)agree
to comply with an city and county ordinances entl state law sharing to building construction,and All of coverings to I S"C" better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes. r �/
(We)agree to save.Indemnify and keep harmless the City of Cupertino against liabilities, J Q
Iudgments,costs and expenses which• may In any way accrue agelma said City In consequence of the granting of this permit. SIG URE PPLICANT 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