R 4740 PERMIT R_ 4 7 4 0
APPLICATION FOR CITY OF CUPERTINO NUMBER
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
�/ i L�tri� RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAMENO roof assembly is required.
rdtiel LC.B.O.If
AD4KSS— EXISTING ROOF QgVERING
� NUMBER OF EXISTING COVERINGS
CONTRAC 'S
/-1 O TO BE REMOVED ,TO BE RETAINED
NAME \J 1
r ADDRESS '� �� COVERING
CITY&ZIP
EXISTING
PHONE' BUILT-UP ROOF ❑
LICENSE - ASPHALT SHINGLES ❑
NUMBER
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 em licensed under provisions of Chapter B(commencing with Section WOOD SHAKES
7000)of Division 3 of the inese end Professions Code,and my license Is In full force and
effect I WOOD SHINGLES ❑
License Claes Llc.Num r 1
Date Contract
OTHER(SPECIFY) "l " ;❑
Nom the LDER DECLARATION PROPOSED
hereby affirm Bu that am exempt from the eenAnycity of county
Lew for the fallowing reason. MAY
V q 1�
(Sec.7031.5,Business and Professions rep Code: Any urs or county which requires a permit to /1 1 (,v C
constructalter,Improve,to file asiordstatany mstructure,prior to Its Issuance,also erequires ovisithe BUILT-UP ROOF ` �7
applicant for such permit License Ills a signed statement that g le Ilceneetl pursuant to the pro of the LI)y
of Bus n eenentlgProfeeelone CotlLawe arel�tet heer 9 s exemt1t lherlth efro action the basic lorof sion 3 the elle ged ur l,Urin r�V
�pp
a ASPHALT SHINGLESexemption.Any violation of Section 7031.5 oy any lcantSper blasts the applicant to
a civil penalty of not more than five huntlretl doller5 -�❑I,eaownerof the property,or myempltoe,sweg s compensation,will do WOOD SHAKES ❑the work,antl the atrucWre la not Intentletl ar ec.7 4,Buslneea antl Profac-
sione Cotle:Tae Coniredofe License Laidn o an
oer(er of property who bullae or WOOD SHINGLES ❑
suchimprImprovements
ereen,sand ar who doended a,orkIfdr agfp ifoygbhle own employees,Drovldetl ghat
such Improvements ere net Intendetl or1SNaor e9Jylfhowever.the building or Improvement
Is sold within one year of completion,the own
will have the burden of proving that he did OTHER(SPECIFY)
not build or Improve tar purpose of cele.).
❑I,as owner of the property,am exclusively 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(e)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
E]I em exempt under Sec. ,B 8 P.C.for this reason
Owner orae
WORKERS COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will mailmen a Certificate of Consent to self-Insure for Worker's Compensation, Buildin .80g
as provided for by Section 3700 of the Labor Code,for me performance of the work for which this .� g
permit isle and 1 9 �� Seismic _
have end will themaintain Worker's Compensation for Insurance,as required by Section Workers 01
the labor Cade,for the performance of l e work for which this permit Is lesuetl.My Worker's
C ns tion In u as alar and Pall number are ^^ ' I,I I Z;:S-\a I/— Total
Ca Policy No. -yVt PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.
(This section need not be completed If the permit Is for one hundred dollars($100)Q]ar IesaJ
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 Lowe of Cali. All roofs shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE a APPLICANT:Compensation
makingthisof
of Code,
you mustuforthwld become
ith comply Applicant understands and will comply with all non point
subject go the Workers Com enafter provisions pf the Leber Cotle,
with such provisions or this permll shell be deemed revoked. Source regulations.
I certify that I have read this application and agate 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 lass"C' rbetter.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-herebY authorize representatives of this to enter upon the above- property for In. �^��
spection purposes. (Ill
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may In any way accrue against said City In consequence
of granting of this permit. SIG NATURE OF APPLICANT DAT
PREINSPECTION: 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
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