R 4759 APPLICATION FOR CITY OF CUPERTINO NUMB R R- 4759
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 ADDRESS
o5 3,--( RESIDENTIAL COMMERCIAL OTHER
OWNERS /J�" HAZARDOUS wasAFIRAREA
VES ❑ If isrMinat. ClassA
NAME roof essemhly is required.
QZ NO ❑ Initial I.C.B.O.#
ADDRESS—G,'�s� EXISTING ROOF COVERING
PHONE 1 gZ NUMBER OF EXISTING COVERINGS
CONTRAC7jQRS
O
NAME " C�J TO BE REMOVED TO BE RETAINED
^
ADDRESS 1 1 SQ \ jam _ �n II� TYPE OF ROOF C01A G
CITY&ZIP LJ
`XJ-^'� ill YVW ISA\ EXISTING 4Lf`C��,o(fQ
PHONE ( BUILT-UP ROOFLICENSE
lFq/y .
NUMBER 2 ASPHALT SHINGLES ❑ 9
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES v
7000)of Division 3 of the Business and Professions Code,and my license is In lull force antl
effect. �
(//��',,�x�� ^/TT �Z l'' WOOD SHINGLES ❑
License Claee�yy_ Lie.Number
111 OTHER(SPECIFY) ❑
Dale Contractor
NER-BUILOFF DECLARA ON PROPOSED
I hereby ffbrm the 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 ID
for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Law(Chapter g(commencing with Section 7000)of Division 3 of the El
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 five hundred dollars($500).):
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sac.7044,Business and Prose.
alone Code:The Contractors License Law does not apply to an owner of property who build°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 edea.If,ill however,the hulloing of ImprovementIs sold
not bullwithinor
prove for purpose
sthe owner-budder will have the burden of proving that he oto OTHER(SPECIFY)
not 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'.License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who bulltl.or Improve°thereon,and who contracts for such projects
with a contractor(a)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
E]I am exempt under Sec. ,B&P.C.for this reason
Owner Dale
WORKER'S COMPENSATION DECLARATION APPLICATION DATEI VALUATION PERMIT FEE
I hereby album under penalty of perjury one of the following declaration: /
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, BUlidm
pe mit is Is for 6y Section 3700 of the Labor Code,for the performance of the work for which this �I �� g
permit Is Issued. Seismic �_
❑I have and will t a pert Worker's Compensation the wokfor Insurance,as required by Section 3700of
iha Labor oda,far the performance of the work for which this permit Is leauatl.My Workers
Comp s Incur c erandPolky mberare: - Total
Carrie Policy N5 I PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATIONRANCE N.C.Q
(Thio section need not be completed if the permitit Is Is for one hundred dollars($100)or lase.) fy J F/%�•
I certify that In the Performance of the work for which this permit Is Issued,I shall not employ
any perso In any manner so as to become subject to the Worker,'Componado a al Ca I. All roofs shall be inspected prior to any roofing material being
form . installed. If a roof is installed without first obtaining an
oat Applicant inspection,I agree to remove all new materials for inspection.
Norl TO A PUCANT: II,after making this erti t of Exemption,you naald lace e Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith cam Iy pP P Y p
with such provisions or this permit shalCbe doomed revoked, Source regulations.
I certify that I have read this application and elate that the some 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 $ss"C"Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In. ^ J _� E�E
spectbon purposes.
(We)agree to save,Indemnify and keep harmless the Clty of Cupertino egdent Ilabllitl°s,
judgments,coats and expenses which may in any way accrue against said City In con,equence
of the gma ling of this permit. SIGNATURE E OF APPLIII IE OF APPLICANT A�
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