R-4622 PERMIT R_ 4622
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1B DAYS OF PERMIT ISSUANCE OR
BUILDING ADDRESS 180 DAYS FROM LAST CALLED INSPECTION.
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p�- / Q �' • ' RESIDENTIAL _ COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
-yl/1� /J S�� YES E] If yes-I understand that a Class A
NAME , ,/ �v rC/ /�- roof assembly is required.
' NO Initial LC.B.O.N
ADDRESS— EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S -/n p
NAME �[ IN.JY�SS/�U� TO BE REMOVED TO BE RETAINED
ADDRESS7 / '/ TYPE OF ROOF COVERING
CITY B ZIP 14-1 �/ o^ v
�J EXISTING
PHONE _G (� 9/ BUILT-UP ROOF ❑
LICENSE IJ .,G
NUMBER '�-/ V ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of jJgia Business and Professions Code,and my license is In full force and
effect' ,7 3S WOOD SHINGLES ❑
License Class / Lie.Number
Date - �5/���Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER OECLARATIO PROPOSED
I hereby affirm that I am exempt from the Contractor's Lice a Lew for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or unty which requires a permit to
construct,eller,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 Lew(Chapter 9(commencing with Section]000)of Division 3 of the
Business and Professions Code)or that he is exempt therefrom and the Was for the alleged ASPHALT Set NGLES �J1 ❑
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to J- IJ //"� /�� •I
a civil penalty of not mare than five hundred dollars($500).): WOOD'SHA S 21 lr�/T�
[D 1,as owner of the property,or my employees with wages as their sole compensation,will do y
the work,and the structure Is not intended or offered for sate(Sec.7044,Business and Profes- i Y 1
sions Code. The Contractor's License Law does not apply to an owner of property who 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.It,however,the building or Improvement N
is sold within one year of completion,the owner-Wilder will have the burden of proving that he did OTHER(SPECIFY) /'r0 ❑
not build or improve for purpose of sale.).
❑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 LC.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such pmjeds
with a contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFG R. INSTALLATION SPECS.
I am exempt under Sec. ,B 8 P.C.for,this reason
owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT EE
I hereby affirm under penalty of perjury one of the fallowing declaration:
I have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, Buildin
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit 1 h issued.
aand, 4 / ,/ Seismic
❑ have end maintain Worker's Compensation Insurance,as required by Section 3700 of / '2/
the Labor Co for the partormanca of the work for wJhich this permit is Issued.My Worker's Total
Compensa' n Insuren c rer antl Polic barer . /�{�
Carrier 6 �`� ePolicy N&I(, �6-*-� PERMIT AUTHORIZATION 0 DATE
CERTIFICATE OF EXE TION FROM WORKERS'
COMPENSATI N INSURANCE IN
(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 w h this perm 1 is issued,1 shall not employ
any person In any manner so as to become sub' m the works 'Comitans tion Laws al Cal,
All roofs shall be Inspected prior t0 y rootirp maMnal being
fornia. installed. If a roof is installed without first obtaining an
DateZ4 -5 Applicant inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Cert.' to of Exemption,yet,should become ,A licant understands and will comply with all non point
subject to the Workers'Compensation provisions oft aWr Code,you must forthwith comply Pp p Y
with such provisions or this permit shall be deemed r oked. source regulations.
I certify that I have read this application and state that the above information is correct.I agree
to comply with all ciryand county ordinances and state laws relating to building conslrudion,and Allr OV In StOb better.
hereby authorize representatives of this city to enter upon the above-mentioned property her Im q
spection purposes.
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities
judgments,costs and expenses which may in any way accrue against said City in consequent NAT RE OF APPLICANT DAT
of the granting of this permit.
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