R-4888 PERMIT R_ 4888
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
-� / WITHIN S F DAYS S PERMIT ISSUANCE OR
WI HIN 1 FROM LAST CALLED INSPECTION,
BUIIIL'DDIINGG ADDD/RESS
ini [ RESIDENTIAL ✓ COMMERCIAL OTHER
OWNER'S� HAZARDOUS FIRE AREA
/(//��n
NAME L✓ `^-'� YES ❑ If yes—I rndeblysta0lhatt a Clan
NO Initial I.C.B.O.H
y
ADDRESS ' /O/ " 7G EXISTING ROOF COVERING
PHONE 3LQ NUMBER OF EXISTING COVERINGS
CONTRA Ili ' LJ.tiJIL 7 L
QAnQ TO BE REMOVED O TO BE RETAINED
NAME
ADDRESSTYPE OF ROOF COVERING
CITY 8 ZIP '� L '
�/,,�j [j v� EXISTING
PHONE `� ` �-7 I r U BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Sectio WOOD SHAKES �]
7000)of Division 3 of the Business and Professions Code,and my license Is in lull force and
effect. e39 - 698l6�[0
WOOD SHINGLES El
License Classo Lic.Number
D.IAM
a/` [ �2 Contractor MLAhj. ER PECIFY) El
OWNER-BUILDER DECLARA ON P D
I hereby affirm that I am exempt from the Contractor's License law for the following reqs
(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 lila a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Lew(Chapter 9(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 live hundred dollars(5500).): OOSS
❑1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD
❑
the work,and the structure is not intended or offered for sale(Sec.7044,Business and Profes-
sions Code: 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.It,however,the building or improvement
issoto within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY)
not bulla or improve for purpose of se
❑I,as owner of the property,am exclusively nontrading with licensed contractors 10 construct
the project(Sec.7044,Business and Professionsrimpov Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO. CQ
apply to c contractors)
owner of property who builds or ie Contra tor's Ln,and who contracts for such projects
with a contexem t unlicensedrSe pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION .SPECS.
❑I em exempt under Sec. ,B 8 P.C.for this reason
Owner oats APPLICATION DATE VALUATION PERMI
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: ., pY /�
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, .•. ! ISI I I. 4 DO BUII
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this VVII (� f
Ir le Issued.
@�^y]J�'have and will maintain Worker's Compensation Insurance,as required by Section 3700 of S B S IC
the Labor Code,for the performance of the work for which this permit is Issued.My Worker's. EP 2
Compen ion Insurance Per and P�ol'cy number are: 1L'n''' � ���� Total
Carner�p i�o_ Policy No.L�o'7 " `PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.] 7>77
UP
(This section need not be completed it the permit is for one hundred dollars(5100)or leas.) (i L
I certify that In the performance of the work for which this permit Is issueQ I shall not employ
any person in any manner so as to become subject to the Workers'Compensation Laws of Cell. All r0 fs shall be inspected prior to dmy roofing material being
fornia. installed. If a roof is installed without first obtaining an
Data 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
subject to the Workers'Compensation provisions of the Labor Cotle,you must forthwith comply pP p y point
with such provisions or this permit shall be deemed revoked. Source regulations. -
I certify that l 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 bullding construction,and
Allr o cover'ngs to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino egelnal liabilities,
judgments,costs and expenses which may In any way accrue against said City in consequence I NATUR F APPLICANT DATE
of the granting of this permit.
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