R 4803 APPLICATION FOR CITY OF CUPERTINO
NUMBER PERMIT
R- 4803
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT - (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
_ WITHIN DAYS PERMIT ISSUANCE OR
WI DANSS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS I 1
SC ` t RESIDENTIAL--&COMMERCIAL OTHER
OWNER'S /'r y nem u Q [40 Ar HAZARDOUS FIRE AREA
/�
YES ❑% If yes—I understand that a Class A
NAME C C oof assembly is required.
1'54S
ADDRESS Nuo (O NO ip Initial I.C.B.O.fI
s �J D ZS EXISTING ROOF COVERING
--
PHONE Wife, --7-311 NUMBER OF EXISTING COVERINGS
CONTRACTO 'S ' 1
C`— TO BE REMOVED�/.�TO BE RETAINED
NAME— ,
fq
ADDRESS Q TYPE OF ROOF COVERING
CITY&ZIP "" • 'mJ•�4t�
lS - l� - ? i EXISTING
PHONE BUILT-UP ROOF ❑
NI
CENSE
i UM13ER 2,�o I ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
hereby affirm that I am Ilcensed 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
effect.
License Class S1 Lic.Number
ZIG 10 9 WOOD SHINGLES ❑
Date �� � ��`�Convector OTHER(SPECIFY) ,� ❑
OWNER-BUILDER DECLARATION s
I hereby affirm that I am exempt from the Contractor's License Lew for the fallowing reason. PROPOSED �� vn 6y
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to A
construct,alter,Improve.demolish,or repair any structure.prior uance.also requires the BUILT-UP ROOF R 9
applicant for such permit to file a signed statement that he Is glnae olsuent to the provisions
the Contractor',License Lew(Chapter 9(commencing wi Sectio W )of Divislon 3 of the
Business and Professions Code)or that he is exampt.fArefrom and ears for the alleged ASPHALTSHINGLE
(,
exemption.Any violation of Section 7031.5 by any appplg(cant f a dr u of$the applicant to Utr
e civll penalty of not more than live hundred dollab(S5D0)J:
❑I,esowneroltheproperty,ormyempio 0ewit a able compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended r off red Sec.7044,Business and Profea-
aloneCode:The Contractor's License La d nt an owner of property who builds or WOOD SHINGLES
Improves thereon,ontl who does such or r el� rough his own employees,Provided that ❑
such improvements are not Intended or offer d 4ale.If,however,the building or Improvement
Is eco id within one year of completion,the owner-0ullder will have the burden of proving that he did OTHER (SPECIFY)
not build or Improve for purpose of sale.). ' ^p
❑1,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 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(s)licensed pursuant to the Contractor's License Law, PROVIDE MFGR.INSTALLATION SPECS.
[]I am exempt under Sec. ,B&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:
[:11 have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, BUlldln
pe mit Is Is for by Section 3700 o1 the Labor Code,for the performance of the work kr which rale Buildingto-..
permit is leeuetl. A I !� A Seismlc ._J. '
❑ have and will maintain Worker's Compeneatlon Insurance,as required by Section 3700 of '�...II r
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's Total
CompenpellO Inau ante cerrl�Policy number ere: L
Carrier `V ✓�L1S Policy N&Swt5 'IQ r PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.] O
(This section need not be completed If the permit Is for one hundred dollars($100)or lees.)
I certify that In the performance of to work for which this permit is Issued,I shall not employ
any person In any manner so as to become subject to the Workers'CompensationLaws of Cell- All r00f.^.sh II b inspected prior to any in mat ri sing
torrid. installed. If a roof is installed without fir6i obtaining an
Date `s Applicant inspection,I agree to remove all new materials for inspection.
NOT CE Tou shouecome
subject t.theoWor eres'Compelna tla n provisionis of thelLabor Code,yoiu must fo thwliitthccomply 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 class"C"or better.
hereby authorize representatives of this city to enter upon the above-menlloned property for In.
spection purposes. q/
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
ludgmenta,costs and expenses which may In any way accrue against said City in consequence
of the granting of this permit. SIGNATURE 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