R 4861 PERMITR_ 48 61
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
1SO DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
Owamp, HAZARDOUS FIRE AREA
/T n VES If yes s I assembly
is req that a Class A
NAME \Jcc���y/��1,', ` (//����11...[ONV� -MMMIAGJ'�/�—� NO root assem6ty is requires tial I.C.B.O.If
ADDRESSy y EXISTING ROOF COVERING
PHONE in NUMBER OF EXISTING COVERINGS
CONTT
TO BE REMOVED TO BE RETAINED
NAME e^
ADDRESS (� ROOF COVERING -
CITY&ZIP v r 2 EXISTING
PHONE ' BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(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 ❑
Llc nee CIa 9--� Lic.Number R-HZA4
Det Contremo
OTHER(SPECIFY) ❑
NER-BUILDER DECLARATIONPROPOSED
haffirm that I am exempt from the Contractors License Lew for the following realij
(Bac.ereb 7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,°Iter.Improve,demolish,or repair any structure,prlor to Its Issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Ia Ikons ureuant to the provisions
of the Contractor's License Law(Chapter a(commencing with Sect n 0)of Division 3 of the ,
exemption.and Professions Coda)or that he le exempt therefrom e t °-¢este for the scant to ASPHALT SHINGLES
ex amass .Any violationProfessions
s Seddon r that a any ap of th i of om r t ufo the appthe alleged v ate'\ -iJV(r
a civil penalty of not more than five hundred tlotlare(5500)),),
Q1,as owner of the property,or my employees it gas Ir a mpenestion,will do WOOD SHAKES ❑��
the work,and the structure Is not intended or oHaro8 lore to a usiness and Profes-
sions Code: The Contractor's LicenseLewd map o n§a f property who builds or WODD SHINGLES JUL 1 Lj
Improves thereon,and who does such work i s If r higowIt employees,provltletl that
such Improvements are not Intended or offer s le if, owe ver,the building or Pmprovoment
Is sold within one year of completion,the ow x ulld will hive the hurden of proving that he old OTHER(SPECIFY)`(TY Ul- GUt-':n IhV
not build or Improve for purpose of sale).
[11,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Proleaslons Code:The Contractors 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 Contractor's License Lew, PROVIDE MFG R. INSTALLATION SPECS.C I am exempt under Sec. ,B&P.C.for this reason
Owner Date
APPLICATION DATE VALUATION P T
WORKER'S COMPENSATION DECLARATION E
I hereby affirm under penalty of perjury one of the following declaration:
0 have and will maintain a Certificate of Consent to self-Insure for Workers Compeneatlon, I BUlldl /
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this I 1/ rII
permit Is Issued. 1 lO Seismic
❑I have and will maintain Worker's Compenaetlon Insurance,as required by Section 3700 of 1,/1 � ILLL
the Labor Code,for the performance of the ork for which this It la issued.My Worker's l I�AJC�I•
'Compo Incur ca ca er tlPollcy mbar era: )I ^ Total
Cerrl Policy y{t PERMIT AUTHORIZATION DATE
CERTIFICATE OFE MPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(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 em toy
any person In any manner so as to become subject to the Workers'Compensation Laws of Vali- All roof.^.shall a inspected prior to any roofing material being
feria' installed. If a roof is installed without first obtaining an
Data Applicant inspection,l agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and will
subject to the Workers'Compensatlon provisions of the Labor Code,you must forthwith comply q PP Comply p y with all non point
with such provisions or this permit shalgbe deemed revoked. Source regulations.
I certify that l have read this application and state that the above Information is correct.(agree
to comply with all city and county Ordinances and state laws relating to bulltling construction,and All roof coverings to be cl &S"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In- J /
selection purposes. '
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities.
. ofthe granting of this perdgments,costs and mit ea which May In any way accrue against said City In consequence SIGNATURE OF APPLICANT
DAT
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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY