R 4652 PER
APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 4652
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
/oS3o ---
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME root assembly is required.
c NO Initial I.C.B.O.If
ADDRESS QJ C '�— EXISTING ROOF COVERING
PHONE a �J "` 2� NUMBER OF EXISTING COVERINGS /
CONTRACT 'S /
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS TYPE OF ROOF COVERING
CITYBZIP ✓�Ll�. Q/
''// EXISTING
PHONE rOO —6 5GZJ�` Z,efl C7 BUILT-UP ROOF
LICENSE
NUMBER / 6 ASPHALTSHINGLES /
LICENSED CONTRACTORS DECLARATION fF
I hereby affirm that I em licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect, 6/+ / (0 L WOOD SHINGLES El
License Close C.3 fes6 LIc.Number ev
Date S Contract — OTHER(SPECIFY) � --
OWNER-BUILDER
OWNER-BUILDERD LARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason. DEC
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to Ob_ 95
construct,after,improve,demolish,or repair any structure,prior to its Issuance,also requires the BUILT-UP ROOF YLrr9
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the G
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES'}' OF t,Ut"a
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to �1NU
a civil penalty of not more than eve hundred dollars($500).): WOOD SHAKES
C]1.as owner of the property,or my employees with wages as their sole compensation,will do ❑
the work,and the structure Is not Intended or offered for eels(See.7044,Business and Profes.
sions Code:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES El
thereon,and who does such work himself or through his own employees, rovided that
Such Improvements are not intended or offered for sale.If,however,the building or Pmprovement
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.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to construct ?q
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 contractor(s)licensed pursuant to the Contractor's License Law, PROVIDE MFGR.INSTALLATION SPECS.
[_1I am exempt under Sec. ,B 8 P.C.for this reason ,
Owner Aare
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: '
❑1 have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, �� BUIId In
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this ¢p d_0 g
parmit.ile leaned.
eve end will maintain Worker's Compensation Inaurence,as required by Section 3]00 of Seismic �_
inabor Code,for the performance of the work for which this permit Is issued.My Worker's Total
Compensation Ins uran a carrier end Policy number are:
ca`"°' . a Policy No.�i✓C 2tSy92 0/ PERMITAUTHO TION DATE
CERTIFICATE EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N,C.[
(This section need not be completed If the permit Is for one hundred dollars S1 00)or leas.)
I certify that In the performance of the work for which this permit Is Issued,I shall not employ
any person In any manner so as to become subject to the Workars'compensation Laws of Cali. All roofs sh II be inspected prior to any roofing m teria sing
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: If,after making this Certificate of Exemption,you should become A licant dtands and will Com I with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP unersp y
with such provisions or this permit shall be deemed revoked. source regulations.
I certify that I have lead this application and state that the above Information Is correct.)agree
to comply with all city and county ordinances and stale laws relating to building construction,and All roof coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spection purposes.
agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, �(As,O /I—
(We) st♦/
judgments,casts and expenses which may In any way accrue against said City In consequence
of the granting of this permit. SIG ATUR F APPLICANT ATE
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