R-4576 APPLICATION FOR CITY OF CUPERTINO PERMIT
u s R R- 4576
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (406)777-3226 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
'. 180 DAYS FROM LAST CALLED INSPECTION.
BUI GADDRESS()\ � ��(^
RESIDENTIAL " \ COMMERCIAL OTHER
OWNE S �, , HAZARDOUS FIRE AREA
\ 1 !I r V ( e—,
te^ VES ❑ If yes s I assembly
i tend that. Class A
NAME \ V 1' \ —I \ roof assembty is required.
— ^ p NO ❑ Initial I.C.B.O.#
ADDRESS - "� ,v R E
PHONE 2^ S — I-( NUMBER OF EXISTING COVERINGS
NAME F
TO BE REMOVED_X_TO BE RETAINED
�./ - �r
ADDRESSTYPE OF ROOF COVERING
CITY a zIP ff '—'y EXISTING
PHONE �I ln� �I 3 BUILT-UP ROOF ❑
CENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONT RS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES yam_.
7000)of Division 3 of the Business and Platefuls s Cod and my license Is In lull force and —v
meat' '"'� WOOD SHINGLES ❑
License CIse aC Uc.Number
Data� _Contract OTHER(SPECIFY) ❑
OWNER-BUILDER ECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the tollawin 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 for such permit to file a signed statement that he Is licensed pursue nt to the provisions• p� p I y�of the Contractor'.License Lew(Chapter 9(commencing with Section 7000)of Dlvision 3 of the fr A d
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($500).): OCT 1 -11 �
❑ C1.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(Sen 7044,Business and Profes-
¢lone Code:The Contractor's License Lew does not apply to an owner of property who builds or WOOD SHINGLESTY �'c AI
Improve.thereon,and who does such work himself or through hie own employees,provided that t1f V�1 �,PNO
such Improvements are not Intended or offered for sale.If,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
01,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Cade:The Contractor's 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(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR. INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.Mr 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: t
I have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, Building `
as provided for by Section 3700 of the Labor Coda,for the performance of the work for which this
permit Is Issued. O 4I I ) •� + Seismic `-
❑1 have and will maintain Worker's Compene tlon Insurance,as requiretl by Section 3700 01 J
the Labor Code,for the performance of the wo for which this permit Is Issued.My Worker's
Com 5c Insure r d Poncy num er are: Total25S
card Policy N l �_ PERMITAUTHO 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 leas.)
I certify that In the performance of the work for which this permit Is Issued,I shell not employ
any pe"Al
ecome sublect to Workers'Comp. eaWn.Lfwe of cell- All roofs shall be inspected prior to any roofin mat n eing
forma. installed. If a roof is installed without first obtaining an
plicant inspection,I agree to remove all new materials for inspection.
eubje�t toEhe WoTO �kare Compan.allon provisions of ihethis 11Laaocate�Cotle,yolu muetulorlhwlthbComply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. Source regulations.
Icalory that I have read thinlyapplication ordinances
state matthe above Information construction.correct)agreeto ), ^ l
herebytywilh ell city repenticounry o ft his cee entlstate teruon thelatingto entinadpropery land All roof coverings
, be Cl S "C Or atter. .l
hereby authorize representatives al this city to enter upon ins above-mentioned property for In. 111
epectlon purposes.
(We)agree to save, Indemnify and keep harmless the City of Cupertino against liabilities,
•
judgments,
the granting of this permit,expenses 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY