R 4793 APPLICATION FOR CITY OF CUPERTINO NUMBER R- 4793
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(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
1 M7 RESIDENTIAL COMMERCIAL OTHER
OWNER'SKA LHAZARDOUS FIRE AREA
�
NAME )-�&ll 1 In�u YES ❑ If yea s I understand that a Class A� roof assembly is required.
NO Initial I.GB.O.#
ADDRESS IP17 LAS RdAat4S EXISTING ROOF COVERING
PHONE ZU —frq Zed NUMBER OF EXISTING COVERINGS
CONTRACTOR'S ,, .. `` `
NAME D W �C�{/ TO BE REMOVED TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP
EXISTING
PHONE BUILT-UP ROOFLICENSE
[�
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license is In lull force and
affect.
WOOD SHINGLES ElLlcenae Cleve 1.1c.Number
Date Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION
hereby allirm that I am exempt from the Contractor's License Law for the topbwl r es n. PROPOSED
IS
7031.5,Business and Professions Code: Any city or county w h!Aulras a It to
construct,alter,Improve,demolish,or repair any structure,prior to its Is nce,also the BUILT-UP ROOF
applicant for such permit to file a signed statement that he is llcensepp0 an na
of the Contractors License Law Chapter g(commencing with Selxron 7 1 DI I of Irll✓-/
• Business antl Proleeslans Codes or that he Is exempt therefrore and ih 11 ad ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant Iola permit s aapplie mtd
a civil penalty of not more than five hundred doiters($ mf.
/
❑I,as owner of the property,or my employee.wl WA masthel q mpenaetlon,.111 do WOOD SHAKES ❑
the work,and the structure Is not Intended or offers to gala 7 ,'Business and Profas-
eloneCode:The Conirector'e License Law does rp�ol ly a ow ref property who builds or WOAD SHINGLES
Improve&thereon,and who does such work himsel rou hsewn em PI 008,Provided that ❑
such Improvements are not Intended or offered for eels. „he ver,the bulltling or Improvement
Is sold within one year of completion,the owner-bulltlei J� ave the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.). 'V
❑1,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Protesalons Code:The Contractor's 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(.)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 a xempt and Se 8 6 P for this r aeon
Owner y.Id et APPLICATION DATE VALUATION PERMIT FEE
WORKE COMPENSATION DECLARATI N
I y effirm under penalty of perjury one of the fallowing declared o ' n
f ❑I have and will maintain a Certificate of Consent to self-Insure for Workers Compensation,
permit to Is for by Section 3700 of the Labor Cotle,forth.performance of the work for which this 14*
! Building
permit Ia have
and 9 Seismic 1_
have antl willfor the performance
Worker's Compensation Insurance,permit Is
Issued.
Section 370001 4 s
the Labor Code,for the pedarmand of the work for which this permit le laeued.My Workers 1QQ /�
Compensation Insurance carrier and Policy number are:
y f/,•r T+96 �D�/ Total
Carrier Policy No. ":1PE9MITAUTHORIZATION 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 em lay
any person In any manner so as to become subject to the Workers'Compensation Laws of all. All roofs shall be inspected prior to any roofing aterial being
forma, 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: It,after making this Certificate of Exemption,you should became
subject to the Workers'Compeneetlon provisions of the Labor Code,you must forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shalpm deemed revoked, source regulations.
I certify that I have read this application and state that the above Information Is carredagree
to comply with all city and county ordinances and state laws relating to building construction,and ZAII 'lcOverin t0Class°C°Of behereby authorize representatives of this city to enter upon the above-mentioned property for In-
epedion purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino apelnst Ilabllltlea,
judgments,costa and expanses which may In any way accrue against said City o consequence
• of the granting of this permit. E F ARPLICAkjDATE
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
OFFICE COPY