R 4764 APPLICATION FOR CITY OF CUPERTINO
PE
NUMBER R- 4 7 6 4
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
O I nn QA_
RESIDENTIAL COMMERCIAL OTHER
OWNERS / HAZARDOUS FIRE AREA
'\ &3 " QV)
i Q ) e r VES ❑ 11 as
assembly st required.that Class A
NAME {--YyL 11 L_l� r 1
NO ❑ Initial I.C.B.O.#
ADDRESS a a�,� 0 EXISTING ROOF COVERING
" _ �^ I
' PHONE
NUMBER OF EXISTING COVERINGS
CON�TOR'S
NAM
T TO BE REMOVED�x� _TO BE RETAINED
T ADDRESSLI�� _ rn' TYPE OF ROOF COVERING
CITY&ZIP l�J EXISTING
PHONE BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSE CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license is In full force and
atlepL WOOD SHINGLES ❑
License Clas Lid.Number �gq�C��y
Date Caniretor OTHER Wiy_(,y � 1996 ❑
'tAWER-BUILDER DECLARATION PROPOSED
I hereby a ml that a exempt ho
the Contractor's License Law for the following reason. VII 7
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to 1Jr t_,UI Z,i I IIVU
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 abatement that he is sensed pursuant to the provisions
' of the Contractor's License Lew(Chapter 9(commencingg wit edlon 70W)of Division 3 0l the
Business and Professions Code)or that he Is exempt4h.fslr and the basis for the alleged ASPHALT SHINGLES ❑
exemption.Any violation of Section 7031.5 by any appllc nt fore ml subjects the applicant to
a civil penalty of not more than five hundred dopa is($50 .) WOOD SHAKES
E]1.as owner of the property,ormy emplo eswlthwe It sole compensation,will do ❑
me work,antl the fracture la not Inlentle He d (Sec.7044,Business and Profea-
slone Cotle:The Contmclor'e License Le d s t to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such wo a hrough his own employees,provided that ❑
such Improvements aro not Intended or d rs,a la.II,however,the building or Improvement
Is sold within one year of completion,the owner-b alder will have the burden of proving that he did OTHER(SPECIFY)
1
not bulld or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor($)licensed pursuant to the Contractor's License Law. PROVIDE MFG R.INSTALLATION SPECS.
El 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
C] tl
I have and will maintain a Celicate of Consent to self-insure for Worker's Compensation, Bui4
as tl for by Section 3700 of the Labor Code,for the performance of to work for which ihls
permit Is Issued.
.�� Seismic
ve and will maintain Worker's Com snit for Insurance,es requlretl by Section 370001
to La or Code,for the performance of IN rk for which this permit is Issued.My Worker's
Co:: a 'on ilia ra cec rand Policy most are: Total
C a r Poll Na` �I I PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.]
(This section need not be completed If the permit Is for one hundred dollars($100)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'compensalmn Laws of Can. All roofs shall be inspected prior to&ny roollIng material being
forma. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
become
subject
lto Eh APPLICANT.
Aorrke a Compensation proviIf,after sionis of thecate labor`Code,Exemption,
must forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. source regulations.
to Icertify plywetlhave read thisapplicationordinance a dst that o taws above information construction,and
hereby authorize
rep and county ordinances and ter u on thel above-ing to above-mentioned
d property
f end All roof coverings to be cies "C"Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spadlan purposes. __
(We)agree to save,Indemnify and keep harmless the City of Cupertino a .Inst liabilities,
judgmenw,costs and expenses which may In any way accrue against said City In consequence
of the granting of this permit. SIGNATURE OF APP CANT 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY ,