R 4693ERMIT
NUMBER R- 4693
APPLICATION FOR CITY OF CUPERTINO
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
X
RESIDENTIAL ' COMMERCIAL - OTHER
OWNER'S
HAZARDOUS FIRE AREA
�`�
YES ❑ ItClassA
NAME `--�� % •
is requiredtand .
NO ❑ Initial I.C.B.O. k
EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS
,,�\
ADDRESS �a�I/fAJ \^`��'��
aS2
PHONE `
Z
CONTRA\C-TOR\'S \ ^
\.3LC�(l
NAME \V�i�QTXL1f� �y\L
TO BE REMOVED TO BE RETAINED
C{J
TYPE OF ROOF COVERING
CITY &ZIP d0 c� `1
€xlS2ldG
PHONE
BUILT-UP ROOF ❑
LICENSE ���
NUMBER
ASPHALT SHINGLES �? I
LICENSED CONTRACTORS DECLARATION
liven r 9
hereby affirm that I em licensed under erosions of Chapter 8 (commencing with Section
WOOD SHAKES g,,,�
7000) of Division 3 of the ss entl Professions Code, and license Is In lull porta and
effect.
(t�y� 2 '995
30'(543
WOOD SHINGLES
License Class Lie. Number p
Data 2 Contractor`Q V� C
ClOF CUPFK IINU
OTHER (SPECIFY)
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the License Lew for the reason.
PROPOSED
(Sec. ]0315, .Improve and Code: Any city or county
e: Any requires a
requirae a permit to
Iwhichssuance,
construct, eller. Improve, repeat any prior to Its 1pursuant also requires the
demolish, or rep
BUILT-UP ROOF
nthatstructure,
for such permit to Ills a signed statement that
to file signed licensed pursuant to the provisions
n
ofOPPI
the g it
of the Contractors License Lew (Chapter 8 (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
e civil penalty of not more than flue hundred dollars ($500).):
pe
C3 1, as owner of the property, or my employees with wages as their sops compensation, will do
WOOD SHAKES ❑
the work, and the structure is not Intended or offered lot sate (See. 7044, Business and Profes-
sionsCode: The Confiractor'a License Law does not apply to an owner of property who builds or
Improves thereon, does himself his
WOOD SHINGLES ❑
and who such work or through 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 sale.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct
the project (Sec. 7044, Business and Professions Cade: The Contractor's License Law tloes 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(s) licensed pursuant to the Contractors License Law.
❑ I am exempt under Sec. ,B & P. C. for this reason
PROVIDE MFG R. INSTALLATION SPECS.
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 will maintain a Certificate of Consent to self -Insure for Worker's Compensation,
for by Section
97-1-
BUlldln `
Building
as provided 3700 of the Labor Code, for the performance of the work for which this
permit Is Issued.
have and will maintain Workers Compensation Insurance, as required by Section 3700 of
L or Code, for the the work for le Issued.
I
Seismic_
_the performance of which this permit My Worker's
Compens'e'i�fQn In �ur�e\ncv e•ntl P,olicy number are:
*5160
Total
Carrier Policy No. J`�"'
PERMIT AU HORIZATIO
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 less.)
I certify that in the performance of the work for which this permit Is issued I shall not employ
All roof.^. shall a inspect d for to any roofing material Bing
any person in any manner so as to become subject to the Workers' Compensation Laws of Cell-
fornia.
installed. If a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If, atter making this Certificate of Exemption, you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
Applicant understands and will comply with all non point
with such provisions or this permit shalgbe deemed revoked.
source regulations.
I certify 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 coverings to be Ss"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes.
^
(Wv) agree to save, indemnify and keep harmless the City of Cupertino against Ilebllltles,
C
judgments, courts and expenses which may In anyway accrue egelnel said City in consequence
of hegriming of this permit.
ATURE 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