R 4998•
OFFICE COPY
PERMIT
499 8
APPLICATION FOR CITY OF CUPERTINO NUMBERR_
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
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RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
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YES ❑ yes - I untletstand that a Class A
NAME V
root assembly is required.
NO ❑ Initial I.C.B.O. N
C�
EXIST NO BOOE COVERING
I
ADDRESS
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PHONE
NUMBER OF EXISTING COVERINGS
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CONTRACT�
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NAME QAA ou«A M Q
-
TO BE REMOVED ��+' TO BE RETAINED
ADDR
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TYPE OF ROOF COVERING
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CITY aEz P'`/�
EXISTING
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PHONE
,BUILT-UP ROOF ❑
LICENSE /
NUMBER 3G
ASPHALT SHINGLES
❑ C
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter S (commencing with Section
WOOD SHAKES �I
7000) of Division 3 of the Business and Professions Code, and my license Is In full force and
-/ {�
effect
License Clas Lic. Number v
eJL„�]J 1
WOOD SHINGLES 2 1996
'
OTHER (SPECIFY) CI I Qtr uUrtri I uYU
,r,T9
Data Contractor
OWNER -BUILDER DECLARATION
PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(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 to mr queries, also requires the
applicant lot such permit to file a signed statement that he Is limps effluent to the provisions
BUILT-UP ROOF ❑
of the Contractor's License Law (Chapter 0 (commencing withSectl ) )�ol Division 3 of the
Business and Professions Cotle) or that he Is exemptth rom e _ th In Is for the alleged
Any Section 7031.5 by
ASPHALT SHINGLES ❑
exemption. violation of any applicant r perm) a ble the appllcant to
a civil penalty of not more than five hundred tlonare 1$500).):
C] 1, as owner of the do
WOOD SHAKES
property, or my employBee s sir ensation, will
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the work, and the structure Is not Intended f 9 Profes-
adere r ( Quainesa and
alone Code: The Contractor's License Lew p 1 e w .property who builds orImpr
wor Im in 9phsownemilding or
ement
WOOD SHINGLES
❑�
such Improvements are not Intended
such Imaoveen,entlwhodoended of ar or a 11 however, the Improvement
of or Improvement
lase to e r of in Il �cwfihave the burtlen Of pravingmethedid
en pr
thinor
OTHER (SPECIFY)
not build provne
for purpose
not build or Improve for purpose of sale.).
sale.).
>�M
❑ I, as owner of the property, am exclusively contracting 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 lm roves thereon, and who contracts for ouch projects
contractor's
with a contractor(s) licensed pursuant to the License Law.
❑ I am exempt under Sec. ,B 8 P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner Date
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE VALUATION
PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaratlon:
❑ 1 have and will maintain a Certificate of Consent to sell -insure for Workers Compensation,
as provided for by Section 37DO of the labor Code, for the performance of the work for which this
mil sissand
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(0 D
Building /
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have and will maintain Worker's Compensation Insurance, as required by Section 3700 of
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71
seismic
1 L or Cotle, for the performance of the work for which this permit Is Issued. My Worker's
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l�)
ompenseil Insuranceearrie�ranePolleyfnumberere: QC—
Carrier Ff��� Po icyNO.Z t+
Total
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.C]
(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 shell not employ
All roofs shall be inspected prior to any roofing material being
any person In any manner so as to become subject to the Workers' Compensation Laws at Cali-
fornia.
installed. If a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
NOT CE m
CE TO APPLICANT: Il, after making this Certificate of Exemption. you should become
subject to the Workers' Compensation provisions of the Labor Code, you utt forthwith comply
Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked.
source regulation
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
r fcov n g to cla "C" or better.
hereby authorize representatives of this city to enter upon the above-monticned property for In.
spection purposes.
(We) agree to save, Indemnify and keep harmless the City of Cupertino against liabilities,
judgments, costs and expenses which may In any way accrue against said City In consequence
of the granting of this Permit.
SIGNATURE OF APPLICANT AT
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