R 47730
0
OFFICE COVV
R- 4 7 7 3
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 7773228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS )
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RESIDENTIAL COMMERCIAL OTHER
OWNER'S L
HAZARDOUS FIRE AREA
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VES If yes – I understand that a Class A
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NAME ` N
roof assembly is required
NO ❑ Initial I.C.B.O.If
PJ "` CN e1 C /
EXISTING. ROOF COVERING
ADDRESS b /� ✓
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PHONE { (6 — Z Z J cir
NUMBER OF EXISTING COVERINGS
CONTRACTOfR'S it
NAME ✓� u 1' S Wy\l^/ n Y T•%�' 1
/
TO BE REMOVED TO BE RETAINED
ADDRESS�I O r] " a�
TYPE OF ROOF COVERING
CITY & ZIP w 0�
F�S.
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PHONE G' N e
BUILT-
BUILT-UP ROOF
LICENSE
NUMBER 6 Z
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 8 (commencing with Section
WOOD SHAKES ❑
7000) of Division 3 of the Business and Pr0lesslons Cotle, and m license Is In lull farce and
effect. '� 5 2 Q 2
3 � J
WOOD SHINGLES ❑ `2/
License Claes � - Lia Numbor --(�
Data L) ' L Con 1%LIJ e J
OTHER (SPECIFY) ❑ T
.far
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OWNER -BUILDER DECLARATION
I hereby
PROPOSED
affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec. 7031.5. Business and Professions Code: Any city or county Which requires a permit to
construct, after, 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 pursuant to the provisions
of the Contractor's License Law (Chapter 0 (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 five hundred dollars ($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 Fell
elone Code: The Contractor's License Law does not apply to an owner of property who builds or
Improves thereon, and who does such work himself or through his own employees, provided that
WOOD SHINGLES ❑
such Improvements are not Intended or offered for sale. It, 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,).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct
the project (Sec. 7044, Business and Profestne Code: 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(e) licensed pursuant to the Contractor's License Law,
❑ 1 am exempt under Sec. ,B 8 P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner oats
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION
PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑ 1 have and will maintain a Certificate of Consent to Self -insure for workers Compensation,
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
Z`Al
Building
permit Is Issued.
�`
2.) ;�'UV
SU
❑ I have and will maintain Worker's Compensation Insurance, as required by Section 3700 of
Seismic
,the Labor Code, for the performance of the work for which this permit Is Issued. My Worker's
Compensatio�n+ Inaurence]1carrier Policy
s
Total 6 57 '75 -
ane numQ[p�r are: /�
Carrier . J T n rT ll to — CJ policy No. `' n O / I
Carrier
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
4,2
TQC N%�K.. CG r
'7
COMPENSATION INSURANCE N.C.I]
(This section need not be completed If the permit IS for one hundred dollars ($100) or loss.)
1 certify that In the performance of the work for which this permit Is issued, I shall not employ
All rCofn shall be inspected prior to any roofing material being
any person In any manner so as to become sub ect to the Workers' Compen anon Laws 01 Cell
forme. d
installed. If a roof is installed without first obtaining an
Date - �j L Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE APPLICANT: If, after making this Certificate of Exemption, you should become
subject to the Workers' Compensation
Applicant understands and will comply v3RhhIl no�i7
provisions of the Labor Code, you must forthwith comply
with such provisions or this permit shelPbe doomed revoked.
point
source regulations.
I certify that I have read this application and state that the above Information Is correct. ) agree
to comply with all city and county ordinances and state laws relating to building construction, and
hereby
All roof coverings to be class "C" or be ®141996
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 against liabilities,QL
�r I (1F 1',(jl+Cly (INV
judgments, costs and expenses which may in any way accrue against said City In consequence
of the greming or this perms.
d•
S I GNATURE 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 COVV