R 4634 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBERR_ 463
4
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
WI180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
lT�lnC iH RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
1 YES E] If yes—I understand that a Class A
NAME V�'` u - /—,o ✓l to �./in P� roof assembly is required.
NO ❑ Initial I.C.B.O.q
Lr i
ADDRESS 1`I )V r5 ""''S ,Q aS C-4 EXISTING ROOF COVERING
'
PHONE I G 1� ^ V NUMBER OF EXISTING COVERINGS -
CONTFF
c( �
/� I %y- J� TO BE REMOVED .J A IG TO BE RETAINED
NAME Q✓l �i �[ L U-(,../ � K�- f K 7
ADDRESS I7 O IF -� �„ ,� [�— /lQ�t � 3� TYPE OF ROOF COVERING
CITY&ZIP .(),IF
V T� -X_L7 87 \ ,
G `x EXISTING
PHONE ���/�y` S� 72 0 BUILT-UP ROOF ❑
LICENSE / ? ? ASPHALT SHINGLES
NUMBER !U GJ ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter S(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Proleeslona Code,and my license Is in lull force and
effec
Licen z WOOD SHINGLES El
nse Cl se ✓ Lia Nu
Date Q comm �96OTHER (SPECIFY) ❑
OWNER-SUIL-111EIRD CLARATION
I hereby affirm that I am exempt from the Contractors License Law for the foil g reason. PROPOSED
(Sec.7031.5,Business and Professions Code: Any city or county which require a ermit to
construct,altar,Improve,demolish,or repair any structure,prior to Its Issuance,also ares the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is licensed pursuant�1�e
visions
of the Contractor's License Lew(Chapter B(commencing with Section 7000)oof the
Buelnesa end Profeaelona Cotle)or that he le exampl therefrom entl the basIII
Ilegatl ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit su cip I to
a civil penalty of not more than live hundred dollars($500).): WOOD SHAKES
❑l,as owner of the property,or my employees with wages as their sole co ane 'd ❑
the work,and the structure Is not Intended or offered for sale(Sec 7044,Bus o
sions Code:The Contractor's License Law it .netepply tor�l.
nor t uldrr WOOD SHINGLES
Improves thereon,and who does such work himself cr lhrougwn e, rovlded that ❑
such Improvements are not Intended or offeretl for eels.I(ho h uor.lmprovement
is not ld bull thinorI provne e for purposelof sakeownarbulitlerwlll hanarpro4ing that he tlltl OTHER(SPECIFY) ❑
not build or improve for purpose of eale.j.
❑l,as owner of the property,am exclusively contracting wl lie ad
c actors to construct
the project(Sec.7044,Business and Professions Code:The Contrecror'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 contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGfl.INSTALLATION SPECS.
❑I am exempt under Sec. ,B 8 R C.for this reason
Owner Dem
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I her y affirm under penalty of perjury one of the following declaration:
have and w10 maintain a Certificate of Consent to self-insure for Worker's Compensation, Building
as=Issued,
provltlad for by Section 3700 of the Labor Code,for the performance of the work for which this C �)
permith v and / r�DV Seismic
❑ have and will maithe pert rmancWorker's f the work
for which ce,this as required by Section 3700's
the Labor Code,for me performance of the work for which ihl9 permit Is laeuetl.My Worker's
Cora I"ure errmr roller are: Total
(arder A Policy No.�py '39_3
PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed If the permit is for one hundred dollars($100)or lees.) a
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 Cali-
All r00 5 Shall be inspected pfl ny roofing m la Bing
rornia. installed. If a roof is inst a without first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
NOTICE shouecome
subject to the OWorkers'C mpelnsation proviAPPLICANT. 1,aher sionis of Chef Labor Code,yolu mustuforthwliitthbcomply Applicant understands and will comply with all non point
with such provisions or this permit shall 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 Alroof coverings to be class" rbetteyp
hereby authorize representatives of this city to enter upon the above-mentioned property for In. /" �O [�r�
epectian purposes. !J 7
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, t
lue menta,costa ono expenses which may In any way accrue against said City In consequence '
of tRe gran0ng of thle permit. 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
�_. _ OFFICE COPY t