R-4566 PERMIT R_ 4566
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSR@CTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 190 DAYS OF PERMIT ISSUANCE OR
180 WITHIN
FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S A I'• � - HAZARDOUS FIRE AREA
NAMETQ��W1 ✓� . V /`V Q/ YES
roof assembly istreqund ired,at Class
NO _ Initial LC.B.O.k
ADDRESS n ,� 9 /�1EXISTING ROOF COVERING
PHONE Q NUMBER OF EXISTING COVERINGS 1 /41I�✓ S•.�.k�
CONTRACTORS
NAME 014� P}Y«/ TO BE REMOVED TO BE RETAINED
ADDRESS PE OF ROOF COVERING
cITY a zIlp G EXISTING
PHONEl� 79 Z Z BUILT-UP ROOF ❑
NUMBER 49 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
effect.
WOOD SHINGLES ❑
License Class Lac.Numbar
Date Contractor t OTHER(SPECIFY) ❑
OWNER BUILDER DECLARATION PROPOSED
hereby affirm Bu Business
1 am exempt from the Contractor's License Lew for the following Permit
.
(Sec.]0315,Business end Prctesar rep Code: Any city or county which ce,also
e permit to
construct,allsuimprove,to
a siorrepeatenystructure,prior to Its Issuance,alsorequires the BUILT-UP ROOF ❑
applicant for such permit to flaw a signed statement that g is licensed pursuant to the provisions
of the ssContractor's o License Law(Chapter 9(commencing with om and th e0)of basis
Division 3 of the
• Business end Professions Code)or the.he Is exempt therefrom end the baste for the alleged ASPHALT SHINGLES $sOO
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty a not more than five hundred donors(h wag): WOOD SHAKES ❑
I,as owner of the property,t I to dedemployees with wages as their sole compensation,will s.
.he work,and the structure is no.intended ores not for sale(Sec.7044,Business and Proles
sons Code: The Contractor's License Lew Boas elft apply loan owner of property who buildsor
Improves thereon,and who does such work himself or through his own employees,provided lent WOOD SHINGLES ❑
such improvements one year
ere not intended completion,or offered for sale.l(however,.he building o iimprovement
notbu ld or I prove f rof purpofs the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve far purpose of Bale.).
I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sac.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 Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
C)I am exempt under Sec. ,B&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: A
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, W,p Buildin
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this ( 4 �/
permit is issued. SFA ��( OO $eISmIC
t have and will maintain Worker's 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 ���`.
Compensation Insurance carrier and Policy number are: - I Total
carriers&k <<44kC- Policy No.11z7y� 9 PERMIT-AUT QRIZATION DATE
CERTIFICA E OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 1Ar�
(This section need not be completed It the permit is for one hundred dollars($100)or lass.)
I certify that In the performance of the work for which this permit Is Issued, shell not employ
any person In any manner so as to become subject to the Workers'Compensa.mn Lews of Celh All roofs shall be inspected Drlor to any offing lariat being
fatale. installed. If a roof is installed witho t first obtaining an
Dale 9� Applicant A tIolk inspection,I agree to remove all new materials for inspection.
NOTI TO APPLICANT: It,after making this Certificate of Exemption,you should become Applicant understands and will I with all non oiht
subject to the Workars'Compensation provisions of the Labor Code,you must forthwith comply PP comply y P
with such provisions or this permit shall be deemed revoked. source regulations.
I certify that I have read this application and slate that the above Information Is correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof coverings to be clas u`.n r atter.
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 liabilities,
. judgments,costs and expanses which may In any way accrue against said City In consequence S NATUR OF LI D
of the granting 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY