R 4729 PERMIT
APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 47 2 9
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
1W DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESSES rix
I O ce " S v T oh ' \ RESIDENTIAL_,C._
�/
COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
VES ❑ If yes—I understand that a Class A
NAME 'Tin wf.4 roof assembly is required.
I.C.B.O.W
1 ADDRESS_ 0 W -:I- d p NO ❑ Initial a 6 1, EXISTING ROOF COVERING
v PHONE Call, 6 1 - NUMBER OF EXISTING COVERINGS a,
CONTRACTORe'SV^y'�� f
NAME ADDRESS TO BE REMOVED TO BE RETAINED
CITY 8Z P �r QI.�LO.n-) 1,B✓LL �+.ame_ q'S71 Z. TYPE OF ROOF COVERING
EXISTING
PHONE V IVI--09 33 BUILT-UP ROOF
LICENSE ZZ
NUMBER ASPHALT SHINGL
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 Cotle,and my license Is in full force and
effect. ^ rn
License Class `-� C WOOD SHINGLES
uc.Number � "T - ❑
Data { ALL 7ContractorI^ OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason. L>3
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,altar,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 g Commencing with Sectlon 70001 of Division 3 of the �-
Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES 30
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not mora than five hundred dollars($500).):
C]1,as owner of theproperty,or my employees with wages as their sole compensation,will s WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(See.7044,Business and Profas-
slonsCoe:The Contractor's License Law does not apply to an owner of property who bullda 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
Is sold within one year of completion,the owner-builder 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 contractors to construct
the project(Sec.7g44,Business and Professions Code:The Contractors 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 proleets
with a contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR. INSTALLATION SPECS.
C]I 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:
❑I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, I !.1 O Iry
as provided for by Section 37110 o1 the Labor Code,for the performano of the work for which this G� Building
per is Issued.
I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of ^ 1996 $eISn11C
I abor Code,lar the performance of the work for which this permit is issued.My Workers, y yy �l
Co penaallonI Insurance carrier and Policy number are: hy,O -77 JAN 61 Total
Carrier S tIR_.C!- YN'� policy No. L
CERTIFICATE OF EXEMPTION FROM WORKERS' VII 1 jr VurPERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE N.C.E3
(This section need not be completed It the permit Is for one hundred dollars($100)or foss.) s'1
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 roofin material being
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
j�oteork If.
sthis
Certificate
mluushould
become
subeihTO APPLICANT:
Compensation provisions of the Labor Co you mstfo forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shalQbe deemed revoked. Source regulations.
I certify that 1 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 rolif renngs t ba ass"C or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes.
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities,
judgments,costa and expenses which may In any way accrue against said City In consequence 41d I
of the granting of this permit. SI A O L 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
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