R 4763 ERMIT
. APPLICATION FOR CITY OF CUPERTINO
NU BER R- 47p_]
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 /1
RESIDENTIALJL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA '
NAME Q�fW e YES ❑ If yes—1 understand that a Class A
roof assembly is required.
NO �{" tribal I.C.B.O.p
ADDRESS
7 7/ � X EXISTING ROOF COVERING
PHONE .— NUMBER OF EXISTING COVERINGS _ 7z
CONTRACTOR'S
,Fy TO BE REMOVED TO BE RETAINED
NAME
ADDRESS TYPE OF ROOF.COVERING
CITY 8 ZIP -
e�P� EXISTING
PHONE i S 7 BUILT-UP ROOF APR 15 R96
LICENSE
NUMBER 6 ASPHALT SHING&r' UI- L.UrcO acv
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Cotle,and my license Is in full torte and
effect. WOOD SHINGLES ❑
License Class / Lic.Number —
Date�f—��j= L- Contractor 's OTHER(SPECIFY) El
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from the Cantreclore Licenoppri
he following reason.
(Sec.7031,5,Business and Professions Code: Any city or cosquires a permit to
construct alter. or repair any structure,prior t -also requires the BUILT-UP ROOF ❑
applicant for such permit to Ills a signed statement that he Is licensed he provisions
of the Contractors License Law(Chapter B(commencing with S1 D son 3 of the
Business antl Professions Cotle)or that he le exempt therefroa Is r the alleged ASPHALT SHINGLESa civil penaAny ltyof oft ion more than ionfive hundred any s($5 0) foJe epplicam toXe civil penalty of not more than flue 031.5 tl any a plican,y❑I,as owner of the property,or my employees with wagesompensation,will do WOOD SHAKES
the work,antl the structure la not intended or oHe 46r�4Q � usiness and Proles.
slons Code:The Contractor's License Law as dappl pyg Dtf owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work hl A r CllllroL9fi hls own employees,provided that ❑
such improvements are not Intended or offers 1 .If;however,the building or Improvement
is sold within one year al completion,the owner III will have the burden of proving that he didOTHER(SPECIFY) Elnot build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.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 comractoga)licensed pursuant o the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
[JI 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:
❑I have and will maintain a Cardficata of Consent to self-Insure for Workers Compensation, Building (b 1
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this ter'\
permit is leaned. - `oOr O l $eISR11C [y„�
❑ have and will maintain Worker's Camps tion Insuran ee required by Section 3700 of !)'s//1 !/
the Labor r the p or nee of the r-Idr whfe Is permit is Issued.My Worker's
'Compena ou�aynce " e d Polley bar ra: �o �'G,�. TOteI
Cerrier— Pati 6y No.�` S��Q�' PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMP N FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need not be completed If the per for one h�ntlred dollen($100)or less.)
I certify that in the performance of the work whit thla p mit is lasued I shell n t employ
any person in any manner so as to become su fact to Wo ars'Compensation L f Call. All roofr.shall be inspected prior to any rooting m aria being
o`nia' / installed. If a roof is installed without first obtaining an
Date s� Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: if,after making this Certlfic of Exemption,you should become A ' ant understands and will comply with all non point
subject to the Workers'Compensation provisions of the L 0,Code,you must forthwith comply p y p
with such provisions or this permit shaifbe deemed ravok ours gulationS. -
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 OV rm S t b CI 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,
judgments,costa and expenses which may In any way accruo ageinet said City In consequence
• of the granting of this permit. SIG R ICANT DATE
PRE-INSPECTION: PLYWOOD: N-PROGRESS:
INSP. DATE INSP.-DATE- NSP. 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