R-4927 PERMIT R_ 4927
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 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER' HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME P/� �� roof assembly is required.
1 NO Initial I.C.B.O.p
ADDRESS s� X/Q �� 1911 C.C�' vl"XZ EXISTING ROOF COVERING
PHONE 3 ` NUMBER OF EXISTING COVERINGS
CONTRAC PRS
jrn �� OJ/I —0 TO BE REMOVED � TO BE RETAINED
NAME + �
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP EXISTING
PHONE !�ea_ 7`7 07-0!V BUILT-UP ROOF ❑
NUMBER ASPHALT SHINGLES ❑ /
LICENSED CONTRACTORS DECLARATION L�
hereby affirm that I em licensee under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 0l the Business and Professions Code,and my license is In lull force and
ane" WOOD SHINGLES ❑
License Class� n Q�2.-/ Lia Number
Data yds ' 9� contractor /h3�.� OTHER (SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I 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,of repair any structure,prior to its issuance,also requires the BUILT-UP ROOF
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions
oI the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Q/1
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 [/
e civil penalty of not more than live hundred dollars(3500).):
C]1, SHAKES I,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 sale(Sec.7044,Business and Profes-
elans Code:The Contractor's Llwnse Law does not apply to an owner of property who bullds or WOOD SHINGLES ElImproves thereon,and who does such work himself or through his own employees,provided that
such improvements are not intended or offered for sale.ll,however,the building 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,am exclusively contracting with licensed contractors to construct
the project(See.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 Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
1 am exempt under Sec. ,B 8 P.C.for this reason
Owner oats APPLICA`fl E VALUATION T FEE
WORKER'S COMPENSATION DECLARATION
I hepd6y affirm under penalty of perjury one of the following declaration:
have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, Wilding
provided for by Section 3700 of the Labor Code,for the performance of the work for which this APR 1 5 IE•C
permit Is issued. - .Seismic
❑1 have and will maintain Workers Compensation Insurance,as required by Section 3700 of 'rte
the Labor Code,for the performance of the work for which this permit is issued.My Workers CI CITY
Ur t,ur'
'Compensation Insurance carr or endpPolicy number are: �p� Cf{I I U,3 7 , Total
cerriar5 o Ul�d PclfayNo.�w __ PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKER5
COMPENSATION INSURANCE N.C.❑ C'rI
(This section need not be completed If the permit Is for one hundred fallen(5100)or le11\�
07
ss.) ��
1 certify that in the performance of the work for which this permit is Issued 1 shall not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Cali. All roofs shall be inspected prior to any roofing material being
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: It,after making this Certificate of Exemption,you should become Applicant understa sand cora I with all non Olnf
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP P Y P
with such provisions or this permit shal¢be deemed revoked source regulatI
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 i ass"C"or better.
hereby authorize representatives of this<Ily to enter upon the above-mentioned property for in-
spection purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
• ofjudgments,gran costs and expenses which may In any way accrue against said City in consequents IG URE OF APPLICANT DATE
of the granting of this permit.
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