R 4732 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBERR_ 4 7 3 2
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
RESIDENTIAL COMMERCIAL OTHER
ow R'S HAZARDOUS FIRE AREA
NAME (fA 45:51 ��I�L��� YES ❑ It yeas I assembly
i req that a Class A
roof assembly is required.
u NO Initial I.C.B.O.#
ADDRESS ` �iS L / !/� A EXISTING ROOF COVERING
PHONE — Q Q NUMBER OF EXISTING COVERINGS Qyr/e5�
CONTRACTOR'S L �1
NAME C.,�-- T •� TO BE REMOVED ��� TO BE RETAINED
ADDRESS 9 I /_S 1 _ / TYPE OF ROOF COVERING
CITU BZIP EXISTING
PHONE /p
���' !n BUILT-UP ROOF ❑
LICENSE p
NUMBER Zp Z ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under loss of Chapter g(commencing with Section WOOD SHAKES ❑
7000)of Division 3 0l the Business and Professions Code.and my license Is In lull lona and
effect.
WOOD SHINGLES
License Claes LIc.Number
C 6G M ,G OTHER(SPECIFY) ElDate � Contractor /��l���,V 10 .00,
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 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 Contractors License Lew(Chapter a(commencing with Section 7000)of Division 3 of 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 appl[cant to
a civil penalty of not more than five hundred dollars($500).):
(J 1.as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profes.
sions Code:The Contractor's License Lew does not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who tloee such work himself or through his own employees,provided that ❑
such Improvements are not Intended or offered for sale.If,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑1.as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code;The Contractor's License Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractor's License Law. PROyIDF.MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B$P.C.for this reason d
Owner Date
WORKER'S COMPENSATION DECLARATION AP TI DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑ 1
I have and will maintain a Certificate of Consent to self-Inure for Workers Compensation, C� vJ •Building
es provided for by Section 3700 of the Labor Code,for the performance of the work for which this n'Ur 0
permit Is Issued. �!I'
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of Lr{/�jy` Seismic J
the Labor Code,for the performance of the work for which this permit is leeuetl.My Workers �i Total
Ce Labor Cod Insurance carrier and Policy number are: -7 9 ( 4 .(� Q —
Carrier � D Policy No. 62d PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.
(This section need not be completed It the permit Is for one hundred dollars($100)or less.)
1 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'Compensotlon Laws of Cali- All roots S al be inspected prior to n oofin ma ng
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
jOto APPLICANT:E TO saimaking iicate at [ ututbecome
subctthe WorkereCompenon provisions of the Labor Code,you msforthwih comply Applicant understands and will comply with all non point
with such provisions or this permit shall be doomed revoked, source regulations.
I certify that I have reed 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 better.
hereby authorize representatives of this city to enter upon the some mentioned property for in. /�/j
6p(We) purposes. —�g / 7(LCL
(We)spree to save,expenses
and keep harmine the City ai Cupertino y In against liabilities, � i,Ly�
of the gran costa and expense which may In any way accrue against said CIN Inconsequence
• onhegranunpathis permit, SIGNATURE 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY