R 4587 APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 4587
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
i RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
// YES If yes—I understand that a Cla A
NANIE (", ,< Z roof assembly is required
/ I NO ❑ Inigat '._ I.C.B.O.N
ADDRESS ,?' '�� G,H r/ /�I r EXISTING F COVERING
PHONE
NUMBER OF EXISTING COVERINGS
/
CONTRTOR'
NAME t / TO BE REMOVED TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP
P', EXISTING
PHONE � _ �',��57--
7_ BUILT-UP ROOF ❑
LICENSE ❑
NUMBER ASPHALTSHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and
effect.
WOOD SHINGLES ❑
License Cl
Lic.Number
Date /—/�j5- Contractor L,'H OTHER(SPECIFY)
OWNER-BUILDER DECLARATIO PROPOSED
I hereby affirm that I am exempt from the Contractors License Law for the followir son.
(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 D /
applicant for such permit toa lila a signed statement nci he Is licensed pursuant to the provisions
the (/
• of the Contractors License Lew)lChapterthat B(commencing with Section 7000)of for the 3 0l the
Business and violation of Code)or that he Is exempt ant for
and the basis for the scantalleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to .�J
a civil penalty of notaries than live hundred dollars($500).);
❑I,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 Prufes.
alone Code:The Contractors 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.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 property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Coda:The Contractors License Low 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 contractogs)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B&P.C.for this reason
Owner Dale
WORKERS COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
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 provitletl for by Section 3700 of the Labor Code,for the performance of the work for which this
permit le Issued. SEP
k 1 $eISn11C
.p_p,�t have and will maintain Worker's Compensation Insurance,as required by Section 3700 o1 LS d 995
tharl9bar Code,for the performance of the work for which this permit is Issuec.My Workers �vs7�6
Component I�'L�Js�ug.�rencre c�erd end Policy number are: ' 'Q� s Total
Carrier. 4%,�`�.19 �� Percy No.�3E - y PE 1 'A(1'F)-IORIZATION DATE
CERTIFI ATE OF EXEMPTION FROM WORK R '
COMPENSATION INSURANCE N.C.I]
(This section need not be completed If the permit Is for one hundred dollars($100)or less.) (_LJ
I certify that in the performance of the work for which this permit is Issued,I shall not employ pa
any person In any manner so as to become subject to the Workers'Compensation Law all. All roofs:shall be inspected prior to any roofing material being
tennis. installed. If a roof is installed without first obtaining an
Date Applicant �/ inspection,I agree to remove all new materials for inspection.
N ICE TO AP ICANh f.after makin n Certifisa of xempti oft ould become Applicant understands and will cora
subject to the Workers'Compensation provielons of the bar Code,yo must forthwith comply PP ply with all non point
with such provisions or this permit shalfbe doomed revoked, Source regulations.
I cantly that 1 have read this application and state that the above information is correct.I agree
to comply with all city and county ordinances and slate laws relating to building construction,and All roof coverings to be class r better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spedlon purposes. C
(We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities, _
judgments,costs and expanses which may in any way accrue against said City In coneequenca• 31 NATUR F APPLICANT ` DAT of the prantug 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
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