R 4733 PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 47 3 3
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
. WITHIN 1B0 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS ,f
/LDS PGI i RESIDENTIAL '� COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
!J" YES El If yes-I understand that a Class A
NAME C /� roof assembty is required.
NO Initial I.C.B.O.a
ADDRESS EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME SSS' TO BE REMOVED---/—/ TO BE RETAINED
ADDRESSC, a TYPE OF ROOF COVERING
'. ra
CITYB ZIP � EXISTING
J
PHONE / v ` ,? � / BUILT-UP ROOF
LICENSE
7
NUMBER ,J J / 36 ASPHALT SHINGLES El
LI NS licensed undo' RACTORS DECLARATION
+ I hereby iaffirmsion loft I em usissuntler provisions of Chapter B(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Cotle,and my license la In lull force and
eOeLi' �r 3 / � 36WOOD SHINGLES
License Class / LIC.Number ❑
Date —�� 9 contractor OTHER(SPECIFY) El
OWNER.BUILDER DECLARAT PROPOSED
I hereby affirm that I am exempt from the Contractor's Llc a Law for the following reason.
(Sec.7031.5,Business and Professions Code; Any city or unty which requires a permit to
construct,alter,Improve,demolish,or repair any structure,pr or to lte lseuance,also requires the BUILT-UP ROOF
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
• of the Contractor's License Lew Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Cotle or that he is exempt therefrom and the belle for the alleged ASPHALT SHINGLES ff�
exemption.Any violatlon of Section 7031.5 by any applicant for a permit subjects the applicant to Y
e civil penalty of not more than live hundred dollars($500).):
❑l,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES
the work,and the structure Is not Intended or offered for sale Sec.7044,Business and Proles- ' i (d
slons Code:The Contractor's License Lew does not apply to an owner of property who builds or WOOD SHINGLES d W
Improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are net Intended or offered for sale.It,however,the building or Improvement V Ut'C-
Issoldwithin one year of completion,the owner-Wilder will have the burden of proving that he did OTHER(SPECIFY) (�iI1Y Vl"
not build or Improve for purpose of sale,)
❑I,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts Mr Such projects
with a contractor(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
1 am exempt under Sec. ,B$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: _ �/)
❑1 have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, BUII Ifl{It Jam_
S as provided for by Section 3700 or the Labor Code,for the performance of the work for which this Gs'i
permit Is issued,
a. �.66 �7� $el IC
-, ❑I have and will maintain Worker'°Compensation Insurance,as required by Section 3]000/ ��(�' d�r L/
„the Labor Cotle,fo the a stance of work for Ion this permit Is laeuetl.My Worker's
' Compensetlon an c !stand c number Total
Carrier L'S^'r Policy No.x"-" C'r" r/�a
63 PERMIT AUT N `DATE
CERTIFICATE OF EX PTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need not be completed little permit Is for one hundred dollars($100)or lees.)
I certify that In the performance of the work br this permit le lesued shall not employ
any person In any manner eo t become sub' to th warkera ca 1.p,neanon Laws m call- All roof. all inspected prior t y roofing ateri g
rornia./ ^�, /J } installed. If a roof is installed w hout first obtaining an
Det, y' �Ajpplicent inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certilicat
pExemrolu muoturoshould
h comply Applicant understands and will comply with all non point
subject to the Workers'Compensation rovislons of the Code,
with such provisions or this permit ahellibe tleemetl revok SOU regulations.
Icertify that l have read this application and state that the above Information is correct.I agree t
to comply with all city and county ordinances and state laws relating to building construction.and Il roof coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purpose$. /
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
judgments conte and expense°which may In any way accrue against aeltl City In consequence
of the gramma m ale permit. L4���(CANT 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
OPPIrr rnpv