R 4751 PERMIT
APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 4751
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 UST CALLED INSPECTION,
BUILDING ADDRESS /�\
OI Z bc. RESIDENTIAL'—COMMERCIAL OTHER
OWNER'S IA1 HAZARDOUS FIRE AREA
1 ,L�,JX 7—�V\ \S I (� VES ❑ If yes—I understand that a ClassA
NAME
�, 1�J( roof assembly Is required;
'T NO Initial I.C.B.O.q
ADDRESS EXISTING ROOF COVERING
PHONE I Z NUMBER OF EXISTING COVERINGS
CONTRAC �'
NAME —Y� S TO BE REMOVED TO BE RETAINED
ADDRESS �� _ tw; TYPE OF ROOF COVERING
CINBZIPnn aa oo\\ lElisiriw
PHONEf(!= BUILT-UP ROOF ❑
LICENSE - ASPHALT SHINGLES ❑ k4z?��NUMBER
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)cl Division 3 of the 13 Iness and Professions Code,and my license la In full force end
effect. C+ 3 —J1���]].� WOOD SHINGLES x� (I❑i•
Cleanse CI eel•_. Lle.Number ` `�
OTHER(SPECIFY) APR
Oats Contractor
11 �9s
NER-BUILDERD C LAA N PROPOSED
I hereby ffirm that I am exempt from the Contractors License Law for the following reason. (;(
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to I r lir (,<Jr f
construct,alter.improve,demolish,or repair any structure,priortolts Issuance,alsorequlreathe BUILT-UP ROOF L❑ffY(J
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
• of the Contractors License Law(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 five hundred dollare($500).): WOOD SHAKES
❑I,as owner of the property,or my employees with wages as their sole compensation,will do ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Prefea-
elons Code:The Contractors 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.If,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 Sate.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and 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 contractor(e)licensed pursuant to the Contractor's License taw. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 6 P.C.for this reason
Owner Date
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 Worker's Compensation, �-
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this Building
permit Is Issued. y� /�.
-11 have and will maintain Worker's Compe eetlon Insurence,as required by Section 3700 of � I YO gOlSmic _ 5
the Labor Code,for the performance of the Irk for which ihls permit le Issued.My Workers
Com o Ineum a errs d Polley n bar are: -� Total
Carr Policy � •�� PERMIT AUTHORIZATION ATE
CERTIFICATE OFEXE ION FROM WORKERS'
COMPENSATION INSURANCE N.C.
(This section need not be completed If the permit IS for one hundred dollars(S100)or less.)
I certify that In the performance of the work for which this permit Is Issued,I Shall not employ
any person in any manner so as to become subject to the Workers'Co nsatlo Laws of call- All roofs shall be inspected prior to any roofing material being
fornl ` ' installed. If a roof is installed without first obtaining an
Dace 1 ppllcant -� Q .� inspection,I agree to remove all new materials for inspection.
NOT Ic TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and will comply
subject to the Workers'Compensation pprovielone of the Labor Code,you must forthwith comply ply with all non point
with such provisions or this permit shall+be deemed revoked. Source regulations.
I certify that 1 have read this application and slate that the above Information Is correct.I agree
to comply with all city and county ordinances and state laws relating to Wilding construction,and All roof coverings to be cl S"C" better.
hereby authorize representatives of this city to enter upon the above-mentloned property for In-
spection purposes.
(We)agree.to Save,Indemnity and keep harmless the City of Cupertino against Ilabi1111es,
jucgm mss,costa end expenses which may In any way accrue against said CIq Inconsequence
of the grenling of Ih 9 permit. SIGNATURE OF APPLICANT DA E
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