R-4577 PERMIT
APPLICATION FOR
CITY OF CUPERTINO NUMBER 8 45 7 7
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3'2'28 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS4? o Kk ^
RESIDENTIALOL COMMERCIAL OTHER
Ow HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME S root assembly is required.
• NO Initial I.C.B.O.H
ADDRESS
EXISTING F C9YERING
G
PHONE �- ` NUMBER OF EXISTING COVERINGS
CONTR
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS - TYPE OF ROOF COVERING
CITY&ZIP
E (STING
PHONE� "� GL) BUILT-UP ROOFLICENSE
❑
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professio s Code,and my license Is In full force and
eel
Li ❑
License Clas D y "! WOOD SHINGLES
Lic.Numb
Dale contract OTHER(SPECIFY) ❑
ER-BUILDE RATION PROPOSED
I hereby aHl t at I em xemp om the Contractors License Law for the followig re
nason. PAID
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,alter,Improve,demolish,or repair any structure,prior to Its issuance,also requires theBUILT-UP ROOF. E]applicant for such permit to file a signed statement that he is licensed pursuant to the provisions
• of the Contractor's License Law(Chapter 9(commencing with Section 7000)Of Division 3 01 the E
opC
Business and Professions Code)or that he is exempt therefrom and the basis for the alleged SPHALT SHINGL S11 1995❑
exemption.Any violation of Section 7031.5 by any applicant for a ermit eublectatheapplicantto L
e civil penalty of not more than live hundred dollen($"0)): WOOD.SHAKER Uf- UUf••`ft I I ,
❑I,as owner of the property,or my employees wllh wage as their sole compensation,will do
the work,and the structure Is not intended or Offeratl for eel (SeoJ044,Business and Profes-p/p. _
sions Code:The Contractor's License Law does not apply to an owner of property who build.orb WOOD SHINGLES ❑
Improves thereon,and who does such work himself or through his own employees,provided that
such improvements are not Intended or offered for sale.If,however,the building or Improvement
is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY)
not bulla or Improve her purpose of sale.). I
❑Lae owner of the property,and exclusively Professions
sCod :The th Contractor's
License
lLa constructnot
the project(Sac. of pr Business antis or improv Cotle:The and who Contracts
License Law does not PROVIDE LC.B.O.REPORT N4
with tont owner of property whobuildsor ie Contrathereon,antl whocontractsfor such projects
with a c m exempt licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I em exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to sell-Insure for Workers Compensation, Build!
as mit Is is for by Section 3700 of the Labor Code,for the performance of the work for which This / ll 1 LI p,�
permit Is issued. Ir/` �lV/_M/�A�_J� eISR11C
❑1 nd will maintain W������orkk$$$is Compens ion Insurance,as requlretl by Section 3700 of
the or C ,for a peto a of the wor for which this permit Ia Issued.My WorJp's Total
Comp carri a olicy num r ere: (1/I
carte PoucyN W PERMIT TION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.
(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 m any manner so as to become subject to the Workers'Compensation Laws of Can- I I shall be inspected prior to any roofin maf�enal=being
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
soli O eOecome
WoP ers'Ca pens tion proafter visions oftheLabor Code,cate of Exemption,
mustOforthwith lbcomply Applicant understands and will comply with all non point
such provisions or this permit shal¢be 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 la s"C"Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
• lodgments,costa and expenses which may In any way accrue against said Clry in consequence SIGNA U XA
APPLICANT DATE
of the granting of this permit.
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