R 4528•
0
•
'4528
PERMIT R_
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 UST CALLED INSPECTION.
BUILDING ADDRESS
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RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
YES ❑ If yes - I understand that a Class A
NAME —
roof assembly is required.
NO Inifial I.C.B.O. H
QQ
EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS Ze
Z'
ADDRESS—
PHONE
CONTRACTOR'S a
�f
TO BE REMOVED TO BE RETAINED
NAME LLrt_ /yy0/
ADDRESS
TYPE OF ROOF COVERING
CITY & ZIP
_ p
EXISTING
PHONE ~7 �0
BUILT-UP ROOF ❑
LICENSE 6 L
NUMBER C
ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
hsreby affirm that I em licensed under provisions of Chapter 8 (commencing with Section
/
WOOD SHAKES ❑
7000) of DIvl6lon 3 0l the Business end Professions Code, and my license le In lull for and
effect.
C, G
WOOD SHINGLES ❑
License Class Llc. Number
OTHER (SPECIFY) ❑
x
Date Contreco
OWNER -BUILDER DE RATION
J�y
I hereby affirm rhes I em exempt from the Contractors License Lew for the following reason.
PROPOSED
(Sec. Bu Code: Any city or county which requires a permit to
and Prolooliah,
`
construct. h . Improve, or rep any prior lolls iaeuanae, alsorequiresprovisions the
atter.Improve, damto
BUILT-UP ROOF /
file signed suitamenair
such permit tatstructure,
applicant IIIA a signed statement that he Is licensed pureuent to the pre
applicant
tr a of the
Ip with Section 7000) of Division 3 0l the
of the Contractors License Law (Chaplet a is exempt
Business end ProCode) or mel he le exempt therefrom the basis for the
and
lesion
exemption. Anyf violation
exemption.
ex of Section 7031.5 by any applicant kr a permit subjects me epPlicent to
applicant to
ASPHALT SHINGLES
more
e civil penalty, of not more men live hundred dollars ($300).):
❑I, as owner of the property, or my employees with wages as their sole compensation, will do
WOOD SHAKES ❑
the work, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Proles-
17) n
alone Code: The Contractors License Law does not apply to an owner of property who builds or
WOOD SHINGLES
improves thereon, and who does such work himself or through his own employees, provided that
such Improvements are not Intended or offered for sale. It, however, the building or Improvement
Is sold within one year of completion, the owner-bullder will have the burden of proving that he did
OTHER (SPECIFY)
not b or Improve for purpose of tie
1. a
❑ I, ea owner of the property, am exclucluslvsly contracting with licensed contractors to construct
h and Pr or Improv Code: The License Lew does not
e
the project (weer
e to
apply
PROVIDE LC.B.O. REPORT NO.
�"
of property and who
who contracts for such projects
P P ry P p l
rose who pursuant
or Contractor's
with a c licensed pureuent to the Cantrector'e License Lew.
License
r'
r l�Ul-tHI N
m exempt
I em exempt antler Sec. ,B d P. C. for this reason
PROVIDE MFGR. INSTALLATION SPEW -
Owner
WORKER'S COMPENSATION DECLARA
owner DgeMay
APPLICATION DATE
VALUATION
PERMIT FEE
I hereby affirm under penalty of perjury one of the following decn:
❑ I have and will maintain a Certificate of Consent to sell-Insureorker's Compensation,
as provided for by Section 3700 of the Labor Code, for the performathe workforwhlch this
permit Is Issued.
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f-si/
�s
Buildin
1 neve and will maintain Worker's Compensation Insumnee, asred by Section 3700 0l
t Le or Code, for the of the for
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$eISmIC ]
performance work which this ps Issued. My Workers
Compensation Insurance artier entl Policy number are:
Total
Carrier a Policy No. �% t- Z
PERMIT AUTHORIZATION
DATE
CERTIFICATE O (EMPTION FROM WO'COMPENSATION INSURANCEN.C.O(This section need not be completed II the permit 13 Icr one hunollars ($100) or less.)I
certify that In the performance of the work for which this permited, I shall not emolay
any In
All roofs shall be inspected prior to any roofing material being
person any manner eo as to become subject to the Workers' Compensatlon Lowe of Cali-
feria.
installed. If a root is installed without first obtaining an
Dale Applicant
inspection, I agree to remove all new materials for inspection.
subjecttothe E TOWorkers' C mpensation provisions ofthelLaborCExemption,
de you must forthwith should
comply
Applicant understands and will comply with all non point
with such provisions or this permit shell be doomed revoked.
source regulations.
I certify that I have read this application and slate that the above Information is correct. I agree
to city co my ccs and rel to dIng c and
withrize esti county of
int.
All toCOV gSZcZlassor better.
and
hereby authoy
hereby authorise
ze rep ter upon
of city to enter upon he abog
this above-mentlon
ve-mentioned
tinned property f
property for In-
spection purposes.
(We) agree to save, Indemnify end keep harmless the City of Cupertino against liabilities,
ludgments, costa end expenses which may in any way accrue against said City In consequence
SIGNATURE APPLICANT DATE
of On.Ingonnlepermit.
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