R 48580
•
•
PERMIT
R_ 4858 .
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-9228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1 S DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL_ COMMERCIAL OTHER
OWNER',9'—)D
HAZARDOUS FIRE AREA
,` {!V
.d'�
YES ❑ If yes– I understand that a Class
NAME `
roof assembly is required.
NO ❑ Initial I.C.B.O. #
D Lg
ADDRESS L',
EXISTING ROOF COVERING
PHONE -- ni Wa
NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME
TO BE REMOVED TO BE RETAINED
ADDRESS
TYPE OF ROOF COVERING
CITY It ZIP U SZ
61)
EXISTING
(� f
PHONE "t /� —� r
BUILT-UP ROOF ❑
LICENSE
NUMBER r 3
7
ASPHALTSHINGL
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed undo, provisions of Chapter B (commencing with Section
WOOD SHAKES ❑
7000) of Division 3 of the Business and Prafeselons Code, and my license Is In full force and
effect' `
Llcenee CI es q Lic. Number
Lie.Cor
WOOD SHINGLES ❑
OTHER (SPECIFY) ❑
- - °� b Nino % �- h S 0
Date
OWNEfl- IEDER D� R TION
hereby affirm that em exempt Irpm t ComOctor'e Ofe�Lew for the following reason.
PROPOSED
(sac . 7031.5, Business entl Prof.esl0na C i%An Lily- ounly which requires a permit to
construct, alter, imp rove, demoliseh?or repalr, yet urs, r tylia issuance, also requires the
for such to the
BUILT-UP ROOF El
pormlttoflle,9'signed am neetl pursuant provisions
of the Contractor's Llcense w (Chapter g c s b 1n 7000) of Division 3 of the
_
Business entl Professlons ).or the xe (a hoer and the basis for the alleged
ASPHALT SHINGLES
exemption. Any violano Se o 7 to or a permit subjects the applicant to
e civil penalty of not mo Jh6n v ndr o 0 ,
❑ I, as owner of the p see with wages as their sole compensation, will do
work, end the atre6lu of kite ed or offered for eels (Sec. 7044, Business and Profes-
WOOD SHAKES Elthe
sions Cod :7heQoddtr or'r eLaw does not apply toanowner ofproperty who builds or
Improves thereon, and who dce . on work himself or through his own employees, provided that
WOOD SHINGLES ❑
such Improvements are not intended offered for edea. however, the building orImprovement
/�
Is the ill
owner -builder will have the burden of proving that he and
OTHER (SPECIFY) ❑
not prove for purpose of sere
not Oulltl or Improve for purpose of sale.).
[D 1, as owner of the properly, am exclusively conlractln with licensed contractors to construct
the project (Sec. 7044, Business and Professions Code: Contractor's License Lew 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 contrectoge) licensed pursuant to the Contractor's License Lew.
[:]I am exempt under Sec. ,B A P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner Data
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 maintain a Certificate of Consent to self -Insure for Worker's Compensation,BUlldln
es provided for by Section 3700 of the Labor Code, for the performance of the work for which this
45�
g
permit is issued.
[31 have entl will maintain Workers Compensation Insurance, as required by Section 3700 of
'� P
/ VO
Seismic
the Labor Code, for the performance of the work for which this permit Is Issued. My Workers
d v
Compensation .In}surancey rrler and Policy number are: q
-UV) 3�
Total *7-1
PERMIT AUTHORIZATION'
C, DATE
Carr leG `� F Policy No. I /�
CERTIFICATE OF EXEMPTION FROM WORKERS'
T
COMPENSATION INSURANCE NCC
(This section need not be completed It the Is for hundred dollars go)
permit one ($1 or less.)
I certify that In the performance of the work for which this permit Is Issued, I shell not employ
xr 0 W- -
All roofs shall be inspected p o any rfl0fing material being
any person In any manner so as to become subject to the Workers' compensation Laws of call.
fornia.
installed. If a roof is ins t withat first obtaining an
Date Applicant
inspection, I agree to remove all n" materials for inspection.
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become
subject to the Workers' Compensation Labor
Applicant understands and will
pP comply with all non
provlelons of the Code, you must forthwith comply
with such provisions or this permit shall be deemed revoked.
point
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 --A4
of Coverings aclass "C"or better.
herebherebyauthorizeumodm representatives of this city to enter upon the above-mentioned property for in
y
n purposes,
spree to saandve, Indemnify and keep harmless the CIry of Cupertino against Ilablllties,
p(We)
othe greeting of this perrmiL ee which may In any way accrue against said City In consequence
SI TORE OF APPLICANT 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY