R 4979•
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a
OFFICE COPY
APPLICATION FOR CITY OF CUPERTINO NUMBIER R- 49 7 9
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
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RESIDENTIAL COMMERCIAL OTHER
OWNER'S_
HAZARDOUS FIRE ARE
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end that a ClaseA
YES ❑ It yes— I undrsta
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root assembly is required.
NO InNal I.C.B.O. IF
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t Q 300-25O
EXISTING ROF COVERING
ADDRESS ,
S A /��Z � � 1 V go &JV�V
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PHONE ' —
NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
'NAME �Cr�A/D h-�� G �/,N�
TO BE REMOVED TO BE RETAINED
ADDRESS
TYPE OF ROOF COVERING
CITY & ZIP L ND+4
EXISTING
f�8% 7%301U
PHONE
BUILT-UP ROOFLICENSE ❑
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'J/ o��3 L
NUMBER to"
ASPHALT SHIN ES Ix
LICENSED CONTRACTORS DECLARATION
I hereby allirm that I am licensed under provisions of Chapter a (commencing with Section
WOOD SHAKES ❑
7000) of Division 3 of the Business and Professions Code, and my license Is In full force and
elect.
����5�
License Class Lic. Number
Date contractors
WOOD SHING
.a
OTHER (SPECIFY)SIO
OWNER BUILDER DECLARATION
hereby affirm that em exempt from the Contractor's License Law for the following reason.
PROPOSED
(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
for file
BUILT-UP ROOF ❑
applicant such permit to a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law(Chapter a (commencing with Section 7000) of Division 3 of the
Business 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
a civil penalty of not more than five hundred dollars ($500).):
❑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 Profes-
sion. Code: The Contractors License Law does not apply to an owner of property who builds or
Improves thereon, and who does such work himself or through his own employees, provided that
WOOD SHINGLES ❑
such Improvements are not intended or offered for sale. If, however, the building or Improvement
Is sold within one year of completion, the owner-bullder will neve the burden of proving that he did
OTHER
not build or Improve for purpose of sate.).
(SPECIFY) ❑
❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct
the project (Sao,7044. Business and Professions Code: The Contractor's License Lew 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 contractoge) licensed pursuant to the Contractor's License Law,
E]I am exempt under Sec. ,B & P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner Date
• WORKER'S COMPENSATION
ION DECLARATION
ATIO
APPLICATION DATE
VALUATION
PERMIT FEE
hereby of th
penalty of perjury one al the following
�j^�
and fllunderi
❑ have antlwillmaintainaCertificate ofConsent to suredeclfor Wo
as mit is is for by Section 3700 of the Labor Code, for the performance of the work for which ihl9
performnforWorker'sComphichthis
permit is issued.
{al haveWorkers
`
�"�/�J
Building`"
Seismic ?d
andwill maintain Compensation required by Section 37Md.
the Leber Cade, for the
® p1�
whichInsurance,this pe
performance of the work for which info permit la issued. My Workers
My Worke s
Compensation Insurance terrier and Policy number are:
Total
_
Carrier 5 1077 Fw.a Policy No. S'7/ J�47* V CelO
fol?,. PRM UTHORIZATION
DATE
CERTIFICATE EXEMPTION FROM WORKERS'
COMPENSATION
_
Vr Ll
INSURANCE N.C.
(This section need not be completed It the is for hundred dollars
re
permit one ($100) or leas.)
I certify that In the performance of the work for which this permit is Issued. I shall not employ
.61
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All roo .• shall be inspectelld prior to any roofing material being
any person In any manner so as to become subject to the Workers' Compensatlon Laws of Calf
fornia,
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
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
Applicant understands and will comply with all non point
pP p y p
with such provisions or this permit shaiQbe 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,andoof
coverings to be class "C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
"L7 /qC
spedlon purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino apainst liabilities,
judgments, costs and expenses which may In any way accrue against said City In consequence
q L/
C\ C.`�
DATE
at thegrantingofthispermit./SIGNATUREOFAPPLICANT
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