R-4601 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBERR_ 4601
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
-2- 139-7 /x'J,t��t
t r RESIDENTIA COMMERCIAL OTHER
-
OWNER'S
HAZARDOUS FIRE AREA V PiK YES ❑ If yes—I understand that a Class A
NAME roof assembly is required.
NO• Initial I.C.B.O.b
ADDRESS I �-1►'�� Lt/'I✓e- EXISTING ROOF COVERING
PHONE ��� i�J'" NUMBER OF EXISTING COVERINGS
CONTRAC OR'S
�� � ^� TO BE REMOVED____J_TO BE RETAINED
E a-=—Y!
NAM9---��� MCc i
ADDRESS TYPE OF ROOF COVERING
CITY 8 ZIP
PHONE BUILT-UP ROOFLICENSE
❑
NUMBER G ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATIO
1 hereby affirm that I am licensed under provisions of Chapter 8(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 ❑
License Claes Llc.Number \
77
Date ✓q'f Contractor OTHER(SPECIFY) ED�— OWNER BUILDER DECLARATION PROPOSED
I hereby affirm that 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 ❑
• applicant lot such permit to lite a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Law(Chapter B(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 ❑
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($501
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(Sec.7044,Business and Protes-
sions Cotle: The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES El
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 (� •�.(n. / s/ e
is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑ CA 14A (,e
not build or Improve for purpose of sale.). X,
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(800.7044,Business and Professions Cotle:The Contractors License Lew 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(e)licensed pursuant to the Contractor's License Law. PROVIDE III INSTALLATION SPECS.
71 am exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION -b
I hereby affirm under penalty of perjury one of the following declaration: ve s Nf
❑I have and will maintain a Certificate of Consent to sell-Insure for Workers Compensation, /�
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this rs� 7 Buildin�
hei
permit is Issued. Gr/ •( 'll]��
7fl have and will maintain Worker's Compensation Insurance,as required by Section 3700 of Ik7 581Sfi11C
t —Labor Code,for the performance of the work for which this permit is issued.My Worker's
Compensation In��sura�n�ce carrieerr antl P�olliff�numbb Ler-ares:: 1 ' 9. CII) Ut' VUPL-H1 iAl/ cz Total
Carrier G)p �-s-s�1✓��-s-4-% oary No.NV' ' �« —77 PERMIT AUTHORIZATION DATE
CERTIFICAT F EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed It the permit is for one hundred dollars($100)or lees.)
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 Call- All roof.^•shall be inspected prior to any roofing material being
fornix. 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 become A licant 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 shalQbe deemed revoked. S( regulation
I certify that I have read this application and state that the above Information la correct.I agree
to comply with all Illy and county ordinances antl state laws relating to building construction,en A O gSt CI "C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property -
spectlon purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, f"f Cr
• judgments,coats and expenses which may In any way accrue against said City In consequence LICANT DA
of the granting of this permit.
TE
PRE-INSPECTION: X PLYWOOD: IN-PROGRESS:
INSP.—DATE INSP.—DATE— INSP.—DATE
TEAR OFF INSPECTION: BATTENS: ji, FINAL:
INSP. DATE INSP.—DATE— INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
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