R 4846 PERMIT R_ 4846
APPLICATION FOR CITY 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
WI180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS ��/'��{'1 1
.e9193 �`''� k nO I I RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE ARE
YES ❑ It yes-I understand that a Class A
NAME roof assembly is required.
NO Initial I.C.B.O.If
ADDRESS EXISTING ROOF COVERING
PHONE — 3 / NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAME O _
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP riji
r7q z
P n a �� �J BUILT-UP ROOF ❑
NIUMBER CENSE Z Z3 ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect. WOOD SHINGLES ❑
License Class Llc.Number
II Date S (�f �� contracto OTHER(SPECIFY) El
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Lew for the Mllowing isi
(Sec.7031.5,Business and Professions Code: Any city or county which requlree 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 pursuant to the provisions ,.
• of the Contractors License Lew(Chapter g(commencing with Section 7000)of Division 3 of the
da)
Business and Professions Coor that he Is exempt erefrom and the basis for the alleged ASPHALT SHINGLES 0
exemption.Any violation of Section 7031.5 by any appIle for a permit subjects the applicant to
e civil penalty of not more than five hundred Oo3 re($50 zs. p
I]I,as owner of the property,or my empl esew g a heir sole compensation,will do WOOD SHAKES `
�• oI"�'J${Jtp
the work,and the structure Is not Intended 011ora or ea �.7044,Business and Profes. n
alone Code:The Contractor's License'Lew d en pl ry or of property who builds or WOOD SHINGLES''llr Vi
Improves thereon,and who doesduch we h el his own employees,provided that UUr �)tl'r
such improvements are Ralfln.� !r
11 sate. I,however,the building or Improvement V
is sold within an year of l6 , s vmeb6ulldor will have the burden of proving that he did OTHER(SPECIFY) ❑not build ar Improve for Pur le:1.I,as owner of the propexclusively contracting with Ilceneetl contractors to Construct
the project(Sec.7044Bustl Professions Code:The Contractors 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 contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFG R. INSTALLATION SPECS.
C]I am exempt under Sec. ,B S P.C.for this reason
Owner
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
! ❑I have and willmalnt37a Certificate of Consent toeperforure for Workers Compensation, l/�/�� /�/ ,.^� Building
as provided for by Sectionmain 3700 of the Labor Code,for the performance of the work/or which this 5 '7f„O(
permit Is Issued. Seismic
❑ have and will the performance
Worker's Compensation Insurance,as required by Section 3700'of s
the Labor Coda,for me pedormance of the work for which this permit Is Issued.My Worker's
Comports �I;na�y/�enc mer and Policy number are: /�� \ TDtaI
Carder C""�- �0 Polity No. `� s ,�S PERMIT AUT ON DATE
CERTIFICATE OXEMPTION FROM WORKERS'
COMPEN ATION INSURANCE N.Op
(This section need not be completed it the permit is for one hundred dollars($100)or lees.)
I certify that In the performance of the work for which this permit Is Issued,I shall not emtoy
any person In any manner so as to become subject to the Workers'Compensation Laws of Kii- All roofs shall be inspected prior to y ro 'ng I being
fornix' installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOT CE TO APPLIANT: I,after making ths Crticate of ecome
subject t.the Workeres'CDmpefnsetlon provisionls ofstheflLabor Code,you mustuforthwlishoutlhbComply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. Source regulations.
I certify that I have read this application and state that the some 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"Crprbetter
hereby authorize representatives of this city to enter upon the above•monfloned property for In-
spection purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, J
judgmeni costa and expenses which may In any way accrue against teltl City In consequence
of the granting of this permit. SIGNATtIIRE 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