R-4604 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBERR_ 4604
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
q`�
RESIDENTIAL —COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
, 0�jn/ YE ❑ If yes—I understand that a Class A
NAME_ - / (^r 2 --FFY���) /✓�–/f. NO of assembly is required
ial LC.B.O.tt
ADDRESS 9S 3 ly l .d"4-5 " EXISTING ROOF COVERING
�/
PHONE S ,3Z'Z, S 7 T 7 NUMB R OF EXISTING COVERINGS
CONTRACTOR'S �.�
TO BE REMOVED TO BE RETAINED
NAME
—
ADDRESS _ TYPE OF ROOF COVERING
CITY&ZIP
EXISTING
PHONE Ir/10 —90 77 BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES
LCENSED CONTRACTORS DECLARATION
hereby affirm
at I am lceneed under provisions of Chapter 9(commencing with Section WOOD SHAKES ❑
700hI
0)of Division 3 of the Business and Professions Code,and my license Is in full force and
effect. WOOD SHINGLES
License Class Lic.Number �
Date Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors 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 Its issuance,also requires the BUILT-UP ROOF Elappllcan110r such permit t0 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 01 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 civil penalty of not more than five hundred dollars,($51
C]1.as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes-
sionsCode:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑
Improves thereon,antl who does such work himself or through his own employees,provided that
such improvements are not Intended or offered hr sale.It,however,the building or Improvement
Ia 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.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.EJP.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects ` r
with 9 contractors)licensed pursuant to the Contractor's License Law, 1 4
❑1 am exempt under Sec. ,B&P.C.for this reason PROVIDIfYF CTALLATION SPECS.
r
Owner Date APPLICATION DATE! VAI ION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: Qh,/
I have and will maintain a Certificate of Consent to salf-insura for Worker's Compensation, �/3/ Build
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this 0 6%_=_
permit is Issued. Seismic
have and will maintain Workers Compensation Insurance,as required by Section 3700 of
Ih bar Code,for the performance of the work for which this permit Is Issued.My Workers
CompensaU nsur ca carrier antl fry numbayale: rixTotal
Carrier �`JJ. Policy Noi-Zr76 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.GQ
(This section need not be completed If the permit Is for one hundred dollars($100)ar 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 he workers'Compensation Laws of Cali- All roofs shall be inspected prior to any r Ofing mat ial Mffig
forms. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It,after making this Certificate of Exemption,you should become
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply Applicant understands and will comply with all non point
with such provisions or his permit shall be deemed revoked. Source regulations.
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 All roof coverings to be class"C"or Per.
hereby authorize representatives of this city to enter upon the above-mentioned properly for In. I
spection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
• ofthe grlan�ting of his permit.
costs and which may in any way accrue against Bald City In consequence SI TORE O AP9 ICA 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