R-4633 PERMIT
APPLICATION FOR
CITY OF CUPERTINO NUMB R R 4633
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1B0 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION,
�
BUILDING ADDRESS O/ /� //7] p �0O - -42- - vex �v/ RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ II yes-I understand that a Class A
NAME roofassembly is required.
NO J Initial I.C.B.O.#
ADDRESS EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S
�
/ M!Ind,-r 1�� J . ��C r TO BE REMOVED 70 BE RETAINED
NAME i 's 6C)
ADDRESS //// �/ / TYPE OF ROOF COVERING
CITY B ZIP 1 b�0 Si 7Yh _s-f. s/9/" �
11 / -EXISTING
PHONE��/ Z'Q-I z —76y7' BUILT-UP ROOF
LICENSE
NUMBER 3 Z ASPHALTSHINGLES El
ICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 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
effect. WOOD SHINGLES E]License Class LIC.Number 4/Z 9117Z
Dale it ra it ContractorC�.1. :..e OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION li PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
fSec.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 lila a signed statement that he is licensed pursuant to the provisions
. of the Contractor's License Law(Chapter 9(commencing with Section 7 KKft of Division 3 of the
Business and Professions Code)or that he is exempt therefrom and the basis for the alleged 'ASPHALT SHINGLES ❑
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than live hundred dollars($5001.): 0 11,1111
the
as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES OCT
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Protes- {I (�
slons Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES U ,
Improves thereon,entl who does such work himself or through his own employees,provided that r
such improvements are not Intended or offered for sale.If,however,the building or improvement
Is sold within one year of completion,the owner-bulkier 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 U
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 contractor(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: � �� pop
I have and will menton a Certificate of Consent to self-insure for Worker's Compensation, /(twy 19� Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Seismic❑1 have and will maintain Workers Compensation Insurance,as required by Section 3700 of
the Labor Code,for the performance of the work for which this permit is issued.My Worker's
Compensatiyon`1J�%},� r (barrier and Poli; numbeJr/�ro: (7�,/ Total
Carrier•'�'- -+' ar
�r /���// Policy No.�/J" WI PERMIT AUT ORI IT DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.C]
(This section need not be completed if the permit Is for one hundred dollars($100)or less.)
I certify that In the performance of the work for 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 rOOfft Aall be inspected prior to any rcfofiMg mvilerill being
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It,after making this Certificate of Exemption,you should became 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 shalObe deemed revoked. Source regulations.
I certify that I have read this application and state that the above informationis correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,and Alhiroof coverings to be Cl "C"or better.
hereby authorize representatives of this city to anter upon the above-mentioned property for in.
spection purposes. (y nlq
(We)agree to save,Indemnify and keep harmless the City of Cupertino against iiabililies,
judgments,costs and expenses which may in any way accrue against said City,kn consequence /SIGNATURE E OF AP L CANT D
of the granting of this permit.
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DA 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