R-4524 APPLICATION FOR CITY OF CUPERTINo
NUMBER PERMIT
R- 4524
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
1B DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTII COMMERCIAL OTHER
OWNER'S 1 1 HAZARDOUS FIRE AREA
/`. l t V I YES [:] 11 yeaI understand thatClass A
NAME /lam ��VJ���JJJ�w ��r 1 111 lllJ/1��, 111 tool assembly is required..
N0*'J Initial I.C.B.O.#
ADDRESS EXISTING ROOF COVERING
PHONE D NUMBER OF EXISTING COVERINGS
CONTRA OR'S
Q TO BE REMOVED TO BE RETAINED
NAME
ADDRESS C/C /� _ y TYPE OF ROOF COVERING
clTv,g..ZIP Jl-J mf) EXISTING
13"usim
PHONE BUILT-UP ROOF ❑
LICENSE NUMBER �� ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ❑
]000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect' WOOD SHINGLES ❑
License Class Lic.Number 06
OTHER(SPECIFY) ❑ -�
Date -BUILDtar
Nom the Contractors
C Rc ION pRO POSED
hereby affirm that am exempt from the Contractors License Lew for the requires
a reason. G,� _ej
(Sac.7031.5,Business and demolish,
or rep Code: Any city or county which requires a permit to V
construct,eller,Improve,to file signed statement
anystructure,Is licenseor to issuance,to the s iBUILT-UP ROOF Com❑ �9/s
applicant for such permit to file a signed statement that he la licensed pursuant 10 the provisions30"In
V
• of the Contractor's License Lew(Chapter 9(commencing with Section]000)of for the 3 of the
Business and Professions Section
or that he Is exempt therefrom and the beats for the applicant
to ASPHALT SHINGLES
exemption.Any violation of SecOon]031.5 by any applicant for a permit subjects the appllceN 10
e civil penalty of not more than live hundred dollars(h wag): r�
❑Irks and
the f thestructure
I not i tmy ended employeeswith (as Sec.their sole compensation,nd Prlll do WOOD SHAKES ❑
the work,antl the structure Is not Intended ores not for sale(Sew owner
of Business and Pros or
Bions Catle:The,Contractor's License Lewdonsnotapplytoan owner of property whobuildsar WOOD SHINGLES )))
Improves thereon,and who does such work himself or through hie own employees,provided that
such Improvements are not Intended or offered for sale.If,however,the building or Improvement
Is notsold bull or
yearof
purpose
sal owner-bullderwill have the burden of proving that he did OTHER(SPECIFY)
not buil 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 Contractor's 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 Law, PROVIDE MFGR. INSTALLATION SPECS.
❑1 em exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this - I� Ti \
permit is five and r 11\ $01SmIC
❑ have and will maintain performance
of th pensellon Insurance,as required by Section 3700 0t.
zo-
the Labor Code,for the performance of the um for which this permit la issued.My Workers Total
Compo s n c trier Policy Afar
are: �� I 1 ^ ' J1
Carrier Pot yNo. LJ `� PERMIT AU NDATE
do
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed if the permit is for one hundred dollars(5100)or lees.)
I certify that In the performance of the work for which this permit is issued I shall not employ
any person In any manner a s to become subject to the Workers'Compensation Laws of Call. All roofs S e inspected prior to any r offing material sing
far _ installed. If a roof is installed without first obtaining an
Date — Appli nt inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this ertificate of Exemption,you a ould b come Applicant understands and WIII comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must to thwith comply pP P Y P
with such provisions or this permit shall be deemed revoked. 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 All roof covering to Ible clla[/sx�fs�C"or be
hereby authorize representatives of this city to enter upon the above-mentioned property for In. .�/�+1x
herebySpeCtU
purposes. _
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may In any way accrue against said City In consequence SIGNATURE APPLICANT 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY