R 4815 PERMIT q_. 4815
APPLICATION FOR CITY OF CUPERTINO NUMBER
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 J ,,(/- '{�
I 0 7/ 4 v J, r w cI/� �t 5 / Jl RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
yti� YES ❑ If yes—I understand that a Class A
NAME f �� I ) G roof assembly is required.
NO ❑ Initial I.C.B.O.#
ADDRESS 7 �O 1^ r "'r/ 0 a^5 �Acr XEXISTING ROOF COVERING
PHONE s S — y 3 c6 NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S ' \ ( � �j '
NAME 10�-�Lw . S l.lU J '(OQ�1 µ— TO BE REMOVED TO BE RETAINED
ADDRESS / ^ TYPE OF ROOF COVERING
CITY&ZIP ('.R � 7. �,3 r ` / 7 c l,t EXISTING
PHONE_!3 L e) 2. 1 q
LICENSE BUILT-UP ROOF
Z ❑ ��
/
NUMBER O ASPHALT SHINGLES ❑ ��
LICENSED
dunderCONTRACTORS
of Chapter 9(c
ION
hereby affirm that I am Business
licensed underprovisions of Chapter 9(commencing with Section and WOOD SHAKES
7000)cl division 3 0l the Business entl Professions Code,end my license la in lull force end ?/O
effect. q
� S J 3 2 WOOD SHINGLES ❑
License Class_L..=_� � Lla.Number-�—� --�-�
Date CZ_ 3 1 � '16 Contractor 0!ti / y W C�47 OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
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,pdorto its Issuance,also requires the BUILT-UP ROOF 13applicant for such permit to file a signed statement that he s licensed pursuant to the provisions
of the Contractor's License Law(Chapter g(commencing will Section 7000)of DIVislon 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 applicant to
a civil penalty of not more than five hundred dollars($500).);
01,°s 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 Freres.
slons 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.II,however,the building or Improvement
Is so Id within one year of completion,the owner-builder will have the bumen 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 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 projects
with a contractor(s)licensed pursuant o the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
E]I am exempt under Sec. ,B a P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
O
I hereby affirm under penalty of pa7ury one of the following declaration: --'(
❑1 have and will maintain a Certificate of Consent to selbinsure for Worker's Compensation, BUIlding +r
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this IJ
permit isv and. Seismic s
[2I have end will maintain Worker's Compensation Insurance,as required by Section 3700 0l J 7
the Labor Code,for the performance of the work lur which this permit Is issued.My Workers
Compensation Insurance terrier entl Policy number�,°)+ Total
4
Carrier
5
7b'a c 0'U P,• Policy No. O J 0IZ �z / PERMIT AUTH TION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed It the permit Is for one hundred dollars($100)100)or lase.) S
I certify that In the performance of the work for which this permit Is issued,1 shell not employ
any person in any mann r so as to become sub t to the Workera'Compensation Laws o/ au. All roofc, bei ected prior to any roofing material being
lornla.� f S f , \ n h installed. If a roof is installed without first obtaining an
Date / / / Applicant _ w ��C inspection,I agree to remove all new materials for inspection.
NOTsubject 2 the Workers'Compensationaftgovlalonls of theficate of Laborr Code,Exemption,
mustforthwithloecome
comply Applicant understands and will comply with all non point
with such provlelons or this permit Shot be deemed revoked. source regulations.
1 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 Iowa relating to building construction.and All r f coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.spection purposes,
t
(We)agree s save,expenses
and keep harmless the City of Cupertino al liabilities,
judgment°,costs entl expense°which may In any way accrue against°old Cl In on°equence
of the granting of this permit. SIGNATURE OF APPLICANT DATE
00 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 r•.nvV