R 4685 (2) ERMIT
APPLICATION FOR CITY OF CUPERTINO
NUMBER R— 4 6 8 5
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
RESIDENTIAL COMMERCIAL OTHER
OWN R'S HAZARDOUS FIRE AREA
YES J;I�lf yes—I understand that a Class A
' NAM roof assembly is required
NO .
���/�) ❑ Initial Lce.O.#�
ADDRE O ( /JO '/�(iV 4.c1— iz+(, EXISTING I
PHONE 7.76 NUMBER OF EXISTING COVERINGS
CONTRACT R'S
r a - 1 , I _ ' C TO BE REMOVED TO BE RETAINED
NAME D d'�^' F^n
ADDRESS
y3s s� �S�r�rrc�! �pyr,t TYPE OF ROOF COVERING
� EXISTING
PHONE J l dd ' �to 2 �vs-,3
s BUILT-UP ROOF 170 D
LICENSE 2
NUMBER 3�I ASPHALT SHINGLES JAJq (3 1996
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 8(commencing with Sec n / WOOD SHAKES C�
7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and �+� �"/� Uf CV/"Cn� u
affect. tfD SHINGLES
License Cl as c _ 3 9 Lic.Number
Date Contractor
gCiz se�J R(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
hereby affirm that am exempt from the Contractor's License Lew for the fallowing reason.
(Sea 70315,Business and demolish,
or rep Code: Any dry or onmry which requires also requires r to
construct,alter,Improve,to file signed sta eo entrthat e,prior to pe Issuance,to theroi the BUILT-UP ROOF ❑
applicant for such permit to La a signed statement nci he is licensed pursuant to the provisions
At the ss an Prof License Law(chapter a(commencing with Section 7000)of for the 3 0r'the
Business end Professions Code)or that he Is exempt ntfortherefrom and the basis for the alleged ASPHALT SHINGLES ❑
exemption.Anyviolationo t More
of Settlors 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of not mare then Ilva hundred dollars($500).):
01,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(Sac.7044,Business and Profes.
sions Code:The Contractors License Law 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.IL however,the building or Improvement //JI/"lt"ila
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER (SPECIFY) Cwal
not build or Improve for purpose of sale.). in
❑1,as owner of the properly,am exclusively contracting with licensed contractors to construct /��/
the projad(See.7044,Business And Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO. :0 C/ 3
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&P.C.for this reason
Owner Dale
WORKER'S COMPENSATION DECLARATION APPLICATION DATEI VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: a I
li-
0 1 have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, r vi /G ( 1 �� Buildin
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this 1 ��
permit is issued.
❑1 have and w111 maintain Workers Compensation Insurance.as required by Section 3700 of Seisty
the Labor code,for the performance of the work for which this permit is issued.My Worker's
CompennssatItion Insnure'nce`carri r;aumber number are: Q��-s Total
Carlile�` ���+�+ Policy No. 1ry S / 9 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O .� �Q I
(This section need not be completed If the permit Is for one hundred dollars($100)or less.) _1
I 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
Data Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: 1L after making this Certificate of Exemption,you should become Applicant understands and will tom
subject to the Workers'Compensation provisions of the Labor Code,you must forthwllh comply ply with all non point
with such provisions or this permit shelllbe 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 taws relating to building construction,and All roof coverings to be class"C"or better.
hereby authorize representatives of this city to anter upon the above-mentioned property for In-
spectionpurposes.
jWe)
(We)agree to save,indemnify and keep harmless the City of Cupertino against Ilablllilea, J/
ludgments,costs and expenses which may in any way accrue against said Oily le consequence
of the granting of this permit. SIG RE F APPLICANT 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
npweR ensu