R 4796 PERMIT R_ 4 7 9 6
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
WI180 DANS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S �� /��� HAZARDOUS I AREA
/Y/ VES ❑ If yeas assembly
is req that. Class A
NAME. NO roof assembly is requirenmal I.C.B.O.#
ADDRESS EXISTING ROOF COVERING
PHONE
NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAMEJAa
TO BE REMOVED TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP
, F�S
ISTING
PHONE �r BUILT-
BUILT-UP ROOF
LICENSE
y NUMBER ASPHALT SHINGLES 10
LICENSED OONTRACTORS DECLARATION �k-�
I hereby affirm that I em licensed under provisions of Chapter B(commencing with Section WOOD SHAKES I7[I
7000)of Division 3 of the Business and Proleaelone Code,and my I canoe is In ful ors entl T /
effect' / / Z
License Cle _ Llc.Number WOOD SHINGLES El
6 l
Date Contractor
OTHER(SPECIFY) ❑
OWNER-BUILDER DECLAR ON PROPOSED
hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(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 the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he le licensed pursuant to the provlelona
' of the Contractor's License Lew(Chapter a(commencing with Section 7000)of Division 3 of the
Buelnese and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of not more than five hundred dollars($500).):
E]1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or Offered for sale(Sec.7044,Business and Proles.
alone Code:The Contractor's License Law does not apply to an owner of property who build$or WOOD SHINGLES ❑
Improves thereon,and who does such work himself or through hl$own employees,provided that
ouch Improvements are not Intended or offered for sale.If,however,the bulltling or Improvement
is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
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 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(s)licensed pursuant to the Contractor's License Lew, PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sac. ,e 6 P.C.for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the fallowing declaration:
❑I have and will maintain a Certificate of Concent to sell-Insure for Workers Compensation. V ad BDlldl
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit of a leeuatl. �pr{ y Seism
_
1 neve and will the performance
Worker's Compensation I Insurance,as required 13 I by Section 3700 0l /�'1Ir{ .d
- the
of
Code,for the performance of thew k for which this permit le leeuatl.My W,,oYrke(.p, , e
Compare atlon a ante arrierand olicynu eros: �J /ya4�"{�� �.I I y Total
Cerner POIIcyNo. '000
-W�01I PER MIT4AUTHPRIZATION DATE
r CERTIFI ATE EN EXEMPTION FROM WORKERS' 1
COMPENSATION INSURANCE N.C.❑
(This section need not be completed If the permit Is for one hundred dollars($100)or leas.)
I certify that In the performance of the work for which this permit Is Issued,I shell not employ
any person In ny mann so s to become subject to the Workers' ompene n Laws of Call. All roofs shall be inspected prior to any roofing ter I eing
lornia. installed. If a roof is installed without first obtaining an
Date Applicant - Inspection,I agree to remove all new materials for inspection.
subject to the Wo k re compenaeiio provisions makllofethei LaborCotl,y Ion,7ou must forthwlbecome
ltlh comply)me Applicant understands and will comply with all non point
with such provisions or this permit shell 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 ss°C" rbetter.
hereby authorize representatives of Ihie city to enter upon the above-mentioned property for In. 0
apectle,slime tea.
(We)sprees cave,Indemnity end keep harmless the Clty of Cupertino said Ci egelnet Ileblli[iea,
of t a r n ing of end expenses which may In any way accrue against eeltl City In caneaquance
of the granting of this permit. SIG E O PLICANT DA Lr—
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
hFFICE COPY