R 4741 PERMIT
APPLICATION FOR clTv of cuPERTINo
NUMB R R- 47 41
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 .J/��/Ll`�
I `JP%,� RESIDENTIAL �L COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
RMAJD /. VES ❑ If yes-I understand that a Class A
NAMEyyY� Q— - roof assembly is= required.NO Initial LC.B.O.IS
EXISTING ROOF COVERING
ADDRESS � -
PHONE
NUMBER OF EXISTING COVERINGS
y CONTRAC 7qi�Z 1
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS TYPE OF ROOF COVERING
CI &ZIP
EXISTIN
PFE , 3 � •
BUILT-UP ROOF ❑
LICENSE ?-oD ASPHALT SHINGLES
NUMBER ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Prafeeslons Code,and my license is In lull force antl
effect' U T/ WOOD SHINGLES L "❑
Licene � Lic.Numb ` `
OTHER(SPECIFYINA 2 19rJ
Date Contractor 90
BUILDER C N �gOPOSED ^fin`
I hereby a Irm that em exempt from the Contractor's LIC Lew for the following reeso h v ' r U
(Sec.7031.5,Business and Professions Code: Any city or u w I requires a permit to r (xUf-CrT
in I ff�V
construct,alter.Improve,demolish,or repair any structure,prior i fiance,also requires the BUILT-UP ROOF ❑
app local for such permit to file a signed statement that he IB fl pursuant to the provisions
of the Contractor's License Law(Chapter B(comma cinpp4iith 8 7000)of Division 3 of the
• Business and Professions Coda)or that he Is axe t'itlore a basis for the alleged ASPHALT SHINGLES ❑
exemption.Any violation of Section 7031.5 by any all a subjects the applicant to
a civil penalty of not more than live hundred dolls) $
❑I,as owner of the property,or my employe e6 with a s ar her sola compensation,will do WOOD SHAKES
the work,and the structure Is not Intended or ere f r Sal q(Sec.7044,Business and Profes-
sions Code:The Contractor's License La M pply IG an owner of property who builds or WOOD SHINGLES
improves thereon,and who does such fit f rt
his own employees,provided that ❑
such Improvements are not Intend .oil r1tl r sglsflf,however,the building or Improvement
Iseoltlwithinoneyeerofcompletlo , ner-byilder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of so
01,as owner of the property,am exclu ely contracting with licensed contractors to construct
the project(See.7044,Business and Professions Code:The Contractors 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(S)licensed pursuant to the Contractor's License Law, PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under See. ,B A P.C.for this reason
Owner Dare
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, '✓- Building
pas ermit
is issued.
by Section 3700 of the Labor Code,for the performance of the work for which this y ^ I �� �OD9
j,- permit is ve and. 1--J1 //� ("�I'.�)J-�`\J $elSrnlC '�
❑ have and will the performance
Worker's Compensation on which this as required by Section Worker's
0l
'.a Labor Code,lour the performance of the k for which this permit Is Issued.My Worker's
Compen nsure a orris :afcyn erer, ^� Total
Carrier Policy No. NI PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXE PTION FROM WORKERS'
COMPENSAT10 NSURANCE N,C.O
(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
any person In any manner so as to become subject to the Workers'Compensation Laws of Cali. All roofs shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Dale Applicant inspection,I agree to remove all new materials for inspection.
subjiect toEthe Workers'Compensation provisions ofetheiflLaborr Cotl,yolu nm,
ustufo thwlith became
comply Applicant understands and will comply with all non point
with such provisions or this permit shal@be deemed revoked. Source regulations.
certify mei have read ounapplication and state tethat roeabove information Iscorrect,ioagreeto 12—
(We)
hereby y with all cityrep ese county of this ccs end ter up n theta ing bavei b mtkig dl prop rtyf and NLl "4, verings to be Cl SS°O°08ttBL hemby authorize representatives of this city to enter upon the above-mentioned property lour In- /� l ispection
purposes. I / 1' 1agree to save,indemnify and keep harmless the City of Cupertino against Ilebllitlee, J r AI /Ik
judgments,costs and expenses which may In any way accrue against said City In consequence
of the granting of this permit. SIGNATURET DA EDA 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY