R-4692 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R— 4692
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN DAYS PERMIT ISSUANCE OR
WI DANSS FROM LAST CALLED INSPECTION.
BUILDING ADDRESSe.
^��� M8IDENTIAl COMMERCIAL OTHER
OWNER'S /rr , , HAZARDOUS FIRE AREA
/ /t /1N /V ' VES ❑ If yeas I understand that a Class A
NAME T W lel I roof assembly is required.
that
NO Initial I.C.B.O.#
ADDRESS l0 �/ e� /Q� g�/ N w0 ��' EXISTING ROOF COVERING
PHONE �' �j �iJ xJ NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
O f� /�� TO BE REMOVED TO BE RETAINED
NAME 4y
ADDRESS' *PE OF ROOF COVERING
CITY&ZIP EXISTING
PHONE BUILT-UP ROOF ❑
LICENSE"" E]NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
affect WOOD SHINGLES
License Class Uc.Number
Data Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's 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.prior to its issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
• of the Contractorsessione Lew(Chapter 9(commencing with Section 7000)of for the 3 of the
Business and violation of Code)or that he Is exempt therefrom and the basis for the applicant
to ASPHALT SHINGLES
exemption.Any violationofhan five
7031.5byany applicant for apermit subjects the applicant to
a civil penalty of not more than five hundred dollars(h wag): WOOD SHAKES
❑Irks and wner
sthctureI not
tendedmy employeeswithwages as hair sola compensation,sanddrill s- ❑
the work,and the structure la not Intended ores not
for stir(Sea owner
of Business entl builds
or
Code: The Contractor's License Lew does elft apply to an owner of property who builds or WOOD SHINGLES ❑
Improves thereon,and who does such ware himself or ,If,ho his own employees,Improvement that
such Improvements are not Intended or owner-builder
for seer.ill however,the hulloing of Improvement
is sold within one year of completion,the ownerbullder will have the burden of proving that he did OTHER(SPECIFY) ❑
not b ' or Improve for purpose of sale.).
I,as owner of the property,em exclusively contracting with licensed contractors to construct
th -(Sea 7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO.
a ly to an owner lfperry who builds orimproves hereon,and who contracts for each prolate
h a coni rector - ansed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am ex ntler Sec. ,B 8 P.C.for this reason
owner Date APPLICATION DATE VALUATION PE IT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of he following declaration:
❑1 have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, [ BUIIdin
permit is is for by Section 3700 of the Labor Cotle,for the performance of the work lot which this NOV -La 1� 5
permit is Issued. �V V 11// $eISmIC
❑1 have and willfor maithe pert Workers f the work
for Insurance,as required by d.My
3700'of
s
the Labor Code,for the performance of the work lar which this permit Is issued.My Worker's rl l t Llf
Compensation Insurance carrier and Policy number are:' f/UY'Cf{I It V Total
Carder Policy No. PERMITAUTHORIZA 10 DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed it the permit is for one hundred dollars($100)or less.)
I certify that In the performance of the work tar which this permit is Issued,I shall not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Cali- All roofs shall be Inspect prior to any roofing matifirial ing
fornia. installed. If a roof is installed without first obtaining an
Dale Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It, her making this Certificate of Exemption,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith 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 he above information Is correct I agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof verings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against Ilabllitles,
of the granting of tand his permit. which may In any way accrue against said City in consequence GNA URE OF APPLICANT D IE
40 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