R-4701 APPLICATION FOR CITY OF CUPERTINO
NUMBER PERMIT
R- 470 1
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
[� it7 RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
/' E]/!1 YES It yes—I understand that a Class A
NAME /�f�q[jL/ �i�/JA/((Yr roof assembly is required.
NO Initial I.C.B.O.q
ADDRESS
20621 ������ EXISTING ROOF COVERING
c � A�
PHONE Z NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAME
CITYRa zip Z 30 �i9/L�r.J oat TYPE OF ROOF COVERING
! � EXISTING
PHONE ,y.«- ?.�� ; BUILT-UP ROOFLICENSE
❑
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 lull force and
effect.
Q r WOOD SHINGLES ❑
License Class �l/ Lic.Number ����J 0—
Date •r1-9 6 Contractor Ce14 f�+i t�'' OTHER (SPECIFY) ,� 77/e
/C
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em 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,altar,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 Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
• Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES 1Z
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500).): WOOD SHAKES
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(Sac.7044,Business and Profes.
signs Code:The Contractor's 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.If,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) El
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 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 Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am 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: '
❑1 have and will maintain a Certificate of Consent to sell-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 ) r,
permit is issued. Seismic ` L
1 have and will maithe performance
Workers f the work
for which ce,this as required is i by Section 3700 of
the Labor Coda,for the performance of the work for which This permit is issued.My Workers ��� Total
Compensation Insurance carrier and Policy number are O 27 '
ar-Carrier Q/d /�+�^�� PolicyNo.�Z2l90J '91- PERI 'AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' co I.
COMPENSATION INSURANCE 100)o vT uuzil� l 1 �lS
(This section need not be completed if the permit is for one hundred dollars($100)or less.) v l/�!��
1 certify that In the performance of the work for which this permit Is issued,1s all not employ
any person in any manner so as to become subject to the Workers'Compene n Laws of Call. All roofs shall be inspected prior to any roofing Material being
forma. installed. If a roof is installed without first obtaining an
Date /f 2 7- 4T Applicant inspection,I agree to remove all new materials for inspection.
subject jo theOWorkers'APPLICANT:
Compensation provisions of thelcate of Labor Code,you mustuforthwld become
lith comply Applicant understands and will comply with all non point
with such provisions or this permit shalcbe 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 stale laws relating to building construction,and All roof coverings to be cls C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for Int
spectlon purposes.
(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
.
of the granting of this permit. SIGNATURE OF-APPLICANT DATE
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, _ _