R 4672 PERMIT R_ 4672
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
•
WITHIN GAYS PERMIT ISSUANCE OR
WI DANSS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
/OJQ RESIDENTIAL—XCOMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME QNI NO roof assembly is required.
s tial - I.C.B.O.e
ADDRESS _S EXISTING ROOF COVERING
PHONE
• NUMBER OF EXISTING COVERINGS
!' CONTRACTOR'S
x TO BE REMOVED TO BE RETAINED
NAME
ADDRESSry�� TYPE OF ROOF COVERING
CITY&ZIP AA.1 //IMG/ 4vo, 0.� , ✓
21.� If D EXISTING a., W /R
PHONE 800 —G �F — 7 �/ D BUILT-UP ROOF �qy' ❑
%'
NIUMBER CENSE (0 8�6 G 6 ASPHALT SHINGLES �/9
LICENSED CONTRACTORS DECLARATION Lf"4,
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES err/ El of Division 3 of the Business and Professions Code,end my license le In full force and G>�
effect S WOOD SHINGLES ❑
License Claes �` Uc.Number
a— r OTHER(SPECIFY) ❑
Date Contractor
OWNER-BUILDER DECLARAJ PROPOSED
I hereby affirm that I am exempt from the Contractors ansa Lew for the following reason.
(Sec.7031.5,Business and Professions Code: Any city unty which requires a permit to
construct,alter,Improve,demolish,or repair any structure,pr Its Issuance,also requires the BUILT-UP ROOF ID
for such permit to Ills a signed statement Install ad pursuant to the provisions
• of the Contractor's License Lew(Chapter 9(co o Ing with ' n 7000)of Division 3 of the
Business and Professions Code)or that Ingi exam the I e the heels for the alleged ASPHALT SHINGLES ❑
exemption.Any violation of Section 7031,6 any spin or permll subjects the applicant to
a civil penalty of sat more than Ilve hpprt6 dollar
❑I,do owner of ins property,o(+hye po e B eas 1heb sole compensation,will do WOOD SHAKES ❑
the work,and the structure is not intern err f a or sale(Sec.7044,Business and chores.
alone Code:The Contractor's License o not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such warty mself or through his own employees,provided that
such Improvements are not Intended or yffere for sale.If,however,the building or improvement
Is sold within one year of completion,the0wner-builder will have the burden of proving that he did OTHER (SPECIFY) 44
rKYi
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractor to construct p
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE LC.B.O.REPORT NO. act 7
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractors)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
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby allIrm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, 00 Building f 1
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
perms L /,S� /..;,
f' 7�
Xit iIssued � ? / Seismic
ev0 and will maintain Worker's Compensation Insurance,as required by Section 3700 of
r Cotle,for the performance of the work for which this permit is Issued.My Worker's
r Compensatlo Insurance carrier and Policy number are: Total
Carder � ✓• £4% (• Policy No.PWL245992-01 PERMITAU TION DATE
CERTIFICATE OF XEM TION FROM WORKERS'
COMPENSATION INSURANCE NCO
(This section need not be completed If the permit Is for one hundred dollars 81 00)or lase,)
I certify that In the performance of the work for which this permit Is Issued shell not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of call- All rocTs shall-be inspected prior to any r g malfterial being
fornla. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOT ecome
subject rEhe WTO mkars'Compensatlon proviPLICANT: It,after sions of the Labor Codes Carfillcato of ,
you must forthwithshould complyApplicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked, Source regulations.
I certity,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 C,pj/a to be Iass"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
ep(We)agreeeee. r
(We)ts,co to Enda,Indemnexpenses
and may
i hay a y the City of Cupertino against liabilities,
• judgments,coat and expenses which meY in any way accrue against said City In consequence
of the granting of this permit §1_G_NATURrOF APPLICANT ir DAT
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