R 4882 PERMIT R_ 488
2
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
• 180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
REIDENTAL �COMMERCIA'l Xy OTHER
-
OWNER'S
/ HAZARDOUS FIRE AREA
NAME ��S. L 'Q VES ❑ If yes—I understand that a Class A -
roof assembly is required.
NO Indli I.C.B.O.A
ADDRESS / ,i�•E / Lt a,/ ,�K/ EXISTING ROOF COVERING
PHONE L .. NUMBER OF EXISTING COVERINGS '
CONTRACTOR'S t
TO BE REMOVED TO BE RETAINED
NAME I L
ADDRESS _ _ TYPE OF ROOF COVERING
r
CITY&ZIP-
_ EXISTING
,n
PHONE �y�/f' �o q-i.IG 9-z BUILT-UP ROOF ❑
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter g(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is in full force and
effect. ❑
WOOD SHINGLES
License Clave G '3 j Lie,Number '
L�_g(p r OTHER(SPECIFY)
Date
40/
com
�- rector �p
OWNER.BUILDER DECLARAT le
PROPOSED �[ /
I hereby affirm that I em exempt from the Contractors Lie nee 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 El
for such permit to file a signed statement that he Is licensed pursuant to the provisions E
• of the Contractor's License Low'Chapter g(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he 19 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 then live hundred dollars($500).):
[2 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 Lew does not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,provided that ❑
such Improvements are not intended or offered for sale.It,however,the building or improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he the 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(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&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
' WORKER'S COMPENSATION DECLARATION A
I hereby affirm under penalty of perjury one of the following declaration: Q/J
❑I have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, 'T� Buildin i
as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which this v "y 1n g
perml '.issued. I% Lr, s7�� Seismic
have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
ih or Cotle,for the performance of the work for which this permit is Issued.My Worker's f.vr,r '
Compensation Insurance carrier and Policy nururggber are; 'Y,/l^' Total
Carrier �� L/_6/kjo� Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed If the permit Is for one hundred dollars($100)or less.)
I certify that In the performance of the work for which this permit Is Issued,I shell 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: ll,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
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.)agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof coverings to be class"C" rbetter.
hereby authorize representatives of this city to enter upon the above-mantlonad property for In.purposes. r
(We)agree to save,Indemnify end keep harmless the City of Cupertino against liabilities(We)agree to save, end keep harmless the City of Cupertino against liabilities, s�
• judgments,coats and expenses which may In any way accrue against said City Inconsequence
of the granting of this permit SI NATO F APPL AN DAT
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 ,