R-4657 PERMIT
APPLICATION FOR CITY OF CUPERTINO,
NUMBER R- 4657
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-9228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
BUILDING ADDRESS
180 DAYS FROM LAST CALLED INSPECTION.
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a O I t M\ t '"Q(^•
RESIDENTIAL COMMERCIAL OTHER
OWNER'S rrr------��� - HAZARDOUS FIRE AREA
Q�G_I_� 1„ vsl„ Q YES ❑ If yes is required.iced. Class
NAME 1 1�l T , ` v, de isand that
NO Initial I.C.B.O.R
ADDRESS SQA �- Ir EXISTING ROOF COVERING
PHONE `�-`� -OS�L� NUMBER OF EXISTING COVERING$
CONTRACTOR' Ir/
NAME Q Sx Sat pC,pVl TO BE REMOVED TO BE RETAINED
IL
ADDRESSoZ / VICt� h17f 2 TYPE OF ROOF COVERING
CITY&ZIP L-.
EXISTING
PHONE iii —Oe-,q? BUILT-UP ROOFLICENSE
❑
NUMBER �� [�I3 S 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.
2 r WOOD SHINGLES ❑
License Class ` Lic.Number
Date
/�Zi_ ContOTHER(SPECIFY) ❑
OWNER-BU ILDractorER CLARATION PROPOSED
at I am exempt
I hereby affirm thfrom the Contractor's License Law for the following reason.
0�
(Sec.]031.5,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 f
applicant for such permit to file a signed statement that he Is licensed Pursuant to the Provisions d
of the Contractor's License Lew(Chapter 9(commencing with Section 7000)of Division 3 of the (?A
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLESY Up �J�7
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).): �h �[/A
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES r urYO
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes.
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 improve man es are not intended or offered for sale.ill however,the building or Improvement ('
notsold bull or
prove for purpose
sale.).
the owner-builder will have the burden of proving that he tli0 OTHER(SPECIFY) ❑ IJV L
not build or improve for purpose of ae ` I
❑I,as owner of the property,am exclusivelyns Code:
contracting with licensedcontractors License
torn to construct 'T
the project(Sec.7044,Business and Professions Cotle:The Contractor's License Law does not PROVIDE LC.B.O.REPORT NO.
apply to an owner of properly who builds or improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 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:
❑I have and will maintain a Certificate of Consent to selbinsure for Worker's Compensation, � ) �^ Io Building _^
as provided for by Section 3'l00 of the Labor Code,for the performance of the work for which this
permit is issued.r-11 have and will maintain Worker's Compensation Insurance,as required by Section 370001 Seismic
,the Labor Code,for the performance of the work for which this permit Is issued.My Worker's
Compensation Insurance Carrier and Policy numbs are: Total
Carrier /�� —4C�-' Policy No,NU.IC—?IO Q PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N C.❑ /
(This section need not be completed It the permit Is for one hundred dollars($100)or less.) 1
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 Cell- All roofs.s II be inspected prior to any roofind material being
fornia. 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: If,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply P Y P
with such provisions or this permit shale be 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 state laws relating to building construction,and All roof coverin to a or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in. -
ap iff agree
sea.
(W
(Wel agreee to save,indemnify and keep harmless the City Cupertino against liabilities,
judgments,
granting of this permit,es which may in any way accrue against said City in consequence 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY