R 4910 APPLICATION FOR CITY OF CUPERTINO
NUMBER PERMIT
R- 4 910
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
'
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
WI180 DAYS FROM LAST CALLED INSPECTION.
BUILDINGADDRESS
ZZ, RESIDENTIAL COMMERCIAL OTHER
owN HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAM • 'T" T"Y S J Croof assembly is required.
NO Initial I.C.B.O.fl
ADDREs
�p EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACT 'S
TO BE REMOVED TO BE RETAINED
NAME
-' ADDRESS . TYPE OF ROOF COVERING
CITYBZIP I tui
PHONE _ L 7� BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES ❑
'LICENSED CONTRACTORS DECLARATION I
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES llrnr/
7000)of Division 3 of the Business and Professions Code,and my license la in full force and
WOOD SHINGLES
License Claes Lic.Number
Data caniraclor OTHER (SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
hereby affirm That am exempt from me e: Any
License Lew for the following naso
(Sec.7031.8, ,improve and Profedemolish,
or re Code: Any ucityrs or county which requires a permit to
construct,alter,Improve,tlemela signed
or d statement
structure.Is kcoo Its Issuance,also requires the BUILT-UP ROOF
of the ant for each permit to Ills a elgnetl statement that g Ish Sectio 7000)of DIAe provisions
of the ss and Contractor's License Lew(Chapter 8(commencing with Section 7000)al for the 301 the
Business and violation of Code)or thet he Is exempt therefrom and the beefs for the applicant
to ASPHALT SHINGLES
exemption.Any violation of Section hundred
by any applicant for a permit subjects the applicant to
e civ11 penalty of not more than five by employees
yeesdollars with
wage
❑Irks and
er the of structure
I not I tended or offered wages as(Sec.their Bole compensation,BusinesadPr fes.l do WOOD SHAKES
sons
work,end the ontr cto Is not Intended or offered for eels(Sea owner
of property
entl wilds or
alone Code:thereon.
Contractor's esLicensesuch Lew does s not apply to an owner al property who builds or WOOD SHINGLES
Improves thereon,entl who does work ed for or through his own employees,provided that ❑
such Improvements are not Intended or offered for sale.If,however,the building or Improvement
Is sold within one year of completion,the ownerbuider will have the burden of proving that he did OTHER(SPECIFY) F-1not 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 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 contractors)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B It P.C.for this reason
OwnerDate
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm untler penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to sell-insure for Workers Compensation, Building
provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit Is Issued. l 1./'1 Seismic
❑I have and will maintain Workers Compensation Insurance,as required by Section 3700 0l l w v /X JlJ
the Labor Code,for the panarmance of the work for which this permit le lesuetl.My Worker'9 I
Compensellon In rants entl Policy number are: '�^..,'�z�.'}l��I� Total
CarriePERMITAUTHORIZATION DATE
CERTIFICATE OF XEMPTION FROM WORKERS'
COMPENS TION INSURANCE N.C.] 4
(This section neetl not be completetl II the permit is for one huntlretl tlollere(5100)or IeeeJ
I certify Ihot In the performance of the work for which this permit le laeuaq I shell not employ
any person In any manner eo es to become sublect to me Workers'Compen Ian Lawe er tau- All roof all be inspected prior y roofi mat rial being
feints' installed. If a roof is installed without first obtaining an
Date APQ t t J inspection,,)agree to remove all new materials for inspection.
NOTICE TO APP (CANT: If,after making.hie ertificate of Exemption,you should become Applicant understands and WIII cora
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP ply with all non point
with such provisions or this permit shall 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 covert' gs to be ass"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
speckon purposes, 5
(Wal agree to save,indemnify and keep harmless the City of Cupertino against liabilities,
ry coats and expenses which may in any way accrue against said CityIn consequence Is
the gran
of the granting of permit. SIG"TURE OF APPLICANT
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
r OFFICE COPY