R 4812 PERMIT R_ 4 812
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
• 1 So DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
RESIDENTIAL-)—,—COMMERCIAL OTHER
O ERs_ HAZARDOUS FIRE AREA
YES ❑ If yes-I understand that a Class A
ME d roof assembly is required.
�Q NO Initial I.C.B.O.#
ADDR �� 0 /��-J�!i/ [// EXISTING ROOF COVERING
L
PHONE ! D NUMBER OF EXISTING COVERINGS
CONTRACTOR' /�
FO e"
NAME TO BE RETAINED
ADDRESS7 TYPE OF ROOF COVERING
CITY 8 ZIP 7'.1-� ✓ �!'C�iC /�1
EXISTING
PHONE �y y '7 45e/! r �� BUILT-UP ROOF ❑
CENSE
NUMBER / ASPHALT SHINGLES
LI Ned and CTORS D Capter 9ON
• 10
hereby iaffirmnion that em licensed under Professions
lona of Chapter B it
with Section WOOD SHAKES
7000)of Division 3 of the Business and Profe991one Cotle,^entl my licen Is In full force a
enact. J/ ge
WOOD SHINGLES ElLicense Class Lic.Number
Data Conlrettor (J OTHER(SPECIFY) ❑
NER-BUILDER DECLARATI PROPOSED
I hereby affirm that 1 em exempt from the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Pmleaslons de: Any city or county which requires a permit to
construct,alter,Improve,demolish,or to ply structure,prior to Its Issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to(Ilea slgnetl at t that he Is licensed pursuant to the provisions
of the Contractor's License Lew.Chapter B rt(endng with Section 7000)of Dlvlelon 3 0l the
•
Bust sea and Professions.COEa o'Ih ff� mpt therefrom and the basis for the alleged ASPHALT SHINGLES
exemption.Any violation-of Section 7 ny pplloanl for a permit subjects the applicant to
a civil penalty d rathenfly In [lots($500).):
C]1,asowns thepro o ynp'`yees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,end th la Mended or offered for sale(Sec.7044,Business and Proles.
slons Code:Th ntr r'e, Icense Law does not apply to an owner of property who builds or WOOD SHINGLES -
Improves tharea ly' w odoes such work himself or through his own employees,provided that ❑
such Improvements not Intended or offered for sale.If,however,the bulltling or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑1,as owner of the property,em exclusively contractlnp with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor($)licensed pursuant to the Contractor's License Law. PROVIDE MFG R.INSTALLATION SPECS.
C1 am exempt under Sec. ,B 5 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
r WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: 1 1
[']I have and will maintain a Cetllloate of Consent to self-insure for workers Compensation, i L`��
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this r ,y Buildin8888
permit Is Issued. Seismic On
❑ have and will the performance
Workrman ee f the work
for Insurance,as required by Section 3700 of MAY 13
the Labor Code,for the pertormand of the work for which this permit 16 Issued.My Workers fYf 7r1(] . os� Total
Compensation Insurance terrier entl Policy number are: 1JJ
Carrier Policy No. L f Y GPER�MITtiAUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.0
(This section need not be completed It the permit Is for one dred tars )or Is J
I certify that In the performance of the work for which IN mil a ed all not employ
any portion In any manner so as to become subject to t orke C ation Law [Call. All roofs shall be inspected prior to any roofing material being
fornla. /
�- installed. If a roof is installed without first obtaining an
at Applicant inspection,I agree to remove all new materials for inspection.
subject to
NOTICE
trie Workeres'Compensaorn provisionls ofthelLaborr Cod a,0618 0 you must fothwtu llfh combe ply Applicant understands and will omply with all non point
with such provisions or mile permit shall be deemed revoked. Source regulations
I certify that I have read this application and state that the above information le correct.)agree
to comply with all city and county ordinances and state laws relating to bulltling construction,entl All roof cover' to be
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spectlon purposes. /`IV,
\ (We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
Judgmenta,costa and expenses which may In any way accrue against said City In consequence
ottRegrennngotthispermit, SIG ATUR AP CAN ATE
PRE-INSPECTION: PLYWOOD: (� ��"p IN-PROGRESS: 1`n
INSP. DATE INSP. CC. DATE INSP. DATE .Iq T
TEAR OFF 114SPPECTION: r BATTENS: FINAL:
INSP. DATE J INSP.—DATE INSP. DATE I�
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY