R 4787 PERMIT R_ 47 8 7
APPLICATION FOR clTv OF cupERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS j��'V�
g73 l t I I Cir " �'" RESIDENTIAL—Z COMMERCIAL OTHER
t
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME roul assembly is required.
/� NO Initial I.C.B.O.a
ADDRESS ` O e-A EXISTING ROOF COVERING
PHONE 'Q 7�Y le NUMBER OF EXISTING COVERINGS
CONTRA
TO BE REMOVED_ TO BE RETAINED
NAME_f
ADDRESSTYPE OF ROOF COVERING
CITY A ZIP U. o X 3 C'.[ /L.IH , EXISTING
PHONE a.i y -'7 66 3 / BUILT-UP ROOF ❑
LICENSE /
NUMBER /9 �� ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is in full torte and .0
efiwct. WOOD SHINGLES 'I
License Claes LIC.Number �qr coyFo
DBIw Contractor
OTHER(SPECIFY) [gl
C�
OWNER the Contractors
DECLARATION PROPOSED
I hereby affirm that am exempt from the e: Any
License Law for the following reason. 3��1,X99
(Sec.7031 It Bushes and Professions Code: Any city or county which requires a permit to
construct,alter,Improve,demoto file signed any prior lolls Issuance,talso o the
BUILT-UP ROOF
of the
for ,such permit to flaw a signed statement that he lith Section
pursuant to the provisions
of Ne Contractor's License Law(Chapter B Is ex a pt t with Section 7000)of for the 3 of the
• Business and violation at Code)or that he Is exempt therefrom and the basis for the ica t to ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 hundred
any applicant fare permit subjects the applicant to
a civil penalty of not more than Ilva huntlretl tlollare($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(Sec.7044,Business and Profea-
aloneCode:The Contractor's License Law does not apply to an owner of property who builds 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 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) ❑
of b dor Improve for purpose of sols.).
owner of the property,em exciusiveiy connecting with licensed contractors to construct
the roject(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
ap y to an owner of property who builds or improves thereon,and who contracts for such projects
wit acontractor(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B B P.C.for this reason
Avner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
/ I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to self-insure for Workers Compensation, BUlldln
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this pp
1 permit Isissued.
`)<p n n SeiBmiC
❑I have end will themaintain Worker's Compensation Insurance,as required Is I by Section 3700 0l S ,
the Labor Code,for the performance of the work for which this permit la Issued.My Worker's p�
•
.the
Insurance carrier and Polley number are: a T018t
o earner Polley No. (v'jj� p UTHORI DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' r
COMPENSATION INSURANCE IN C.O
(This section need not be completed if the permit is for one hundred dollars($100)or leas.) f7/
I certify that in the performance of the work Ii is
Ich Ihis permit is lbeued,I shell not employ
any person In any manner so as to become subj 1 the Workers'Compensation Laws of Call- All roofs shall be inspectedlYrrorto any roofing material being
fornia. EX installed. If a roof is installed without first obtaining an
/tea Applicant inspection,l agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,atter making this Certificateof Exemp Ion,you should become Applicant understands and will comply with all non Olnf
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP P Y P
with such provisions or this permit shalObe 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 coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes. IS
(We)agree io save,Indemnity and keep harmless the City of Cupertino against liabilities, (��y
judgments,coat.end expenses which may in any way accrue against said City in consequence 4
of the granting of Nis permit SI ATURE 0-APPLICANT ATE
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