R-4921 PERMIT R_ 4 9 21
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 ADDRES
RESIDENTIAL COMMERCIAL OTHER
OWNER'S . HAZARDOUS FIRE AREA
/f YES ❑ It yes-1 understand that a Class A
NAME v roof assembly is required.
NO Initial I.C.B.O.a
ADDRESS EXISTING ROOF COVERING
PHONE UMBER EXISTING COVE GS
CONTRACTOR'S \
S !' REMOVE TO BE RETAINED
NAME J
ADDRESS /�/� /n TYPFQE.AOOF COVERING
CITY&ZIP_
EXISTING � F
PHONE C — BUILT-UP 1-1001-
LICENSE
OOF D,Tj ❑
,y
LICENSE S 3�/ l SPHALT\SHAKES NUMBERLICENSED CONTRACTORS DECLARATIONr 90AI hereby affirm that I am licensed under provisions of Chapter P(commencing with SectlonKES- Vo7000)of Division 3 of the Business and Professions Cade.and my license Is In full force antl �,! l ff73�effect' NGLES v ❑License Class Llc.Number Date ' Contractor �`� ECIFY) :^ p 1OWNER-BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractors License Law for the following reason, y sJ O(Sec.7031.5,Business antl Professions Cade: Any city or county which requires a permit toI tl 1996construct,alter,Improve,demolish,or repair any structure,prior to its issuance,also requires the F ❑
epplicenI for such permit to file a signed statement that he le licensed pursuant to the provisions Iof theContractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of ther V!' VtBusiness antl Professions Cotle)or that he is exempt therefrom and the basis far the alleged HINGLES Lf t I Urexemptl0n.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not mora then five hundred dollars($500).): KES ❑
❑I,as owner of the property,or my employees with wages as their sole compensation,will do
the work,and the structure Is not Intended or offered for sale(Sec.7044,B,_,m s,andP��ppfa
elan Cotle:The Contractor's License Law does not apply to an owner of Or0$ertywwhpbLlW$ ®WOOD SHINGLES ❑
Improves
thereon,and who does such work himself or through his own empldgefie,pr vitle t99etdd
such improvements are not Intended or offered for Bala.It,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.).
I,as owner of the properly,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 contractors)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B S P.C.for this reason
OwnerDate
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 sell-Insure for Workers Compensation, S ./e3(/' qBuilding
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
Ou—
permit Is issued. � Seismic
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of -7d(
�(�. d o
the Labor Code,for the performance of the work for which this permit is Issued.My Workers Total
Compen�atio/n}aAsurence ,er/rj/aJ antl Policy ygber ar, J �""'T I-00_0
Carter V G `^ P�� CPoucy NSA(/ PERMIT AUTHORI DATE
CERTIFICATE OF EXE TION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed If the permit Is for one hundred dollars($100)or lass.) _14
I parity that in the performance of the work for which this permit Is Issued,I shall not employ
any person In any men er so as to become subject Workers'Compensation Laws of Cell. All roofs shall be inspected prior to any roofing material being
fornia. �l G/ installed. If a roof is installed without first obtaining an
Date > 6— pplicant inspection,I agree to remove all new materials for inspection.
NOTCE TO ecome
subject I.the Worrkerss'CCompensation provisionls ofethe flLabor Code,cate of Exemption,
mustufo forthwithshould complyApplicant understands and will comply with all non point
with such provisions or this permit shalPloo deemed revoked. Sour Ula'ions.
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 oOf CO rings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes. 7 G
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may in any way accrue against said City in consequence SIGNATUR PLI ANT DATE
of the granting of this permit.
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
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