R 4986 PERMIT R_ 4986
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
\ADDRESSPre //�
~ LJ y ` FIESIDENTII COMMERCIAL OTHER
OWNER' HAZARDOUS FIRE AREA -
VES [:j It yes—I understand that a Class A
NAME roof assembly is required.
elill, NO ❑ Initial I.C.B.O.e
-�� ADDRESS `- L EXISTING ROOF COVERING
PHONE <- — ® NUMBER OF EXISTING COVERINGS I
CONTRACTO
NAME 7 TO dE REMOVED TO BE RETAINED
_AME C1 _
ADDRESS TYPE OF ROOF COVERING
CITU 8 ZIP EXISTING
PHONE � 3 BUILT-UP ROOF
LICENSE
NUMBER ASPHALT SHINGLES ❑
LIC CTORS DECLARATION
I hereby affirm the m licensed under provisions of Chapter B(commencing with Section WOOD SHAKES
7000)of DII1 3 otrSB elneee entl Prol9eslons Code,and my license Is In lull tome and
effect.
�1�7 ��O
License Claes 1 Lic,Number �1 WOOD SHINGLES
� OTHER(SPECIFY) ❑
Date Contractor 049
OWNER-BUILDER c RAD PROPOSED
1 hereby estrus that em exempt from the e: Any
License Lew for the requires
a remit
(Sec.70315,Business and demolish,
or rep Code: Any city or count'which re also a permit to
construct alter,Improve,to file asigned statement that
prior lopeissuance,alwrequires the BUILT-UP ROOF
applicant tr such permit a Ills a signeddr 9(co ant that,% Is licensed 7000)ofto the provisions
the
of the Contractors License Lew(Chapter B is ex a pt with omSectionand 7000)of for the 3 le ed
.
eBusinessxemption.
and Proleeslone Code)or that he le exempt tans for
entl the baste for the applicant
t0 ASPHALT SHINGLES ❑
exemption.Any violation of Section 70315 by any applicant br a permit subjects the applicant to
e civil penalty of not more then five hundred dollen with
wage WOOD SHAKES❑I,ea owner stheproperty,t Intended doyeaewith wagee aetheir sale compensation,welltlo ❑
the work,end the structure le not sLaw ores not
for mala(Sea owner
of Business and ulIds or
Improves
Code;The,and
who d License Lew does s not apply to an owner of property who provided
t or WOOD SHINGLES ❑
Improves thereon,end who does such work offered
or.If,how his own employees,provided that
such Improvements are not completion,
leb n,th elwnetl br leer.It however,the building pr or Improvement
Issold tbuild or
prove for purpose
sale.)twnerbulltlerwlll have the burden of proving that he tlltl OTHER(SPECIFY) ❑
not bulla or Improve for purpose of ealeJ.
❑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(a)licensed pursuant to the Contractors License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B S P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
r
I hereby affirm under penalty of perjury one of the following declaration: �". 4-
� L'
[)I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation,
ae provided for by Section 3700 of the Labor Code,for the performance of the work for which this 1
(,! Building
permit Is lesuetl' L Seismic _45-0❑1 have end well maintain Worker's Compensation Insurance,as required by Section 3700 of
the Labor Code,for the performance of the work r which this permit to Issued.My Worker's Q p/�
Compense I Buren c rear en ynumb are: Total sa `7s
Carrmr Poll y N . 'l PERMIT AUTHORIZATION DATE
CERT KATE OF EXEMPTI FROM WORKERS'
COMPENSATION INSURANCE NAI]
(Tele section need
the not be completed If the permit Is for one huntlmtl sued,I shall($100)not
less.) �L Ati'70r�4JeG _7 V
certify them thinner so as to of me work for which this permit Is issued, shall not employ
any person in any manner so as m bosoms subject to ma Workers'Compensation Laws m cen� 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 TO APPLICANT: If,after 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 shell be deemed revoked. - Source regulations.
I certify that I have read this application and state that the above Information le correct.I agree
to comply with all city and county ordinances and State laws relating to building construction,and All roof coverings to be Cl %`or better. /
hereby authorize representatives of this city to enter upon the above-mentioned property for in. n
spection purposes. / t _`
(We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities, �J OP ri��
judggents,coats and expenses which may In any way seems agea Bald City In sone---encs
• of t e granting of INS 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY