R 4563 (2) PERMITR" 4563
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
t U� IS gG�J�W Q.�
RESIDENTIAL COMMERCIAL OTHER
OWNERS
- HAZARDOUS FIRE AREA
MC r 1/1 VES ❑ If yes—I understand thatClam A
NAME J� Z` 111 lAA1ii.��� �' 1 notassembly uun is required.. ss
NO Initial I.C.B.O.k
ADDRESS /f /(lJ EXISTING ROOF COVERING
PHONE `/(C9 9-a NUMBER OF EXISTING COVERINGS
CONTRA OR's
I I
NAME TO BE REMOVED TO BE RETAINED
ADDRESS —I ' I t r•-/` /y /]a /� TYPE OF ROOF COVERING
CITU BZIP I /V U`�"
EXISTING
PHONE BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES f�C
LICENSED CONTRACTORS DECLARATION T
hereby affirm that 1 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
affect. WOOD SHINGLES
License Clae Lit.Number
Date 5 racto
OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor&License Lew for the following reason.
(Sec.7031.5,Business and Professions Coda: Any city or county which requires a permit to Iy� '/
construct,alter,such
Improve;to file demolish, statement that
phos tolls lseuance,to
the BUILT-UP ROOF �C` /
applicant for such permit to lila ah,or re atatem&st that he Is prior
its
pureuce al the provisiquires ns
the
of the Contractor's License Law(Chapter 8(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($500).):
❑l,as owner of the property,or my employees with wage$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-
_ &lona 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.If,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the burden of Droving 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(Sec.7044,Business and Professions Code:The Contractors 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 project&
with a contractor(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
C]I am exempt under Sec. ,B 8 P.C.for this reason
Owner Dery
WORKER'S COMPENSATION DECLARATION APPLICATION DATE1 VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this oy t"� 1
pormll,is Issued. ��
I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of Seismic
.in Labor Code,for the performance of the work for which this permit Is Issued.My Worker's T rr� 4 -.y
$ C pe atlon Insurance carrier a Policy number are: �'�I Y '
Carrie •J Policy No. I PERMITrAUTHORIZATION DATE
/CERTIFICATE EXEMPTION FROM WORKERS' '"',�
COMPENSATION INSURANCE N.C.❑
(This section need not be completed If the permit is for one hundred dollars($100)or lase.)
I certify that In the performance of the work for which this permit Is issued,I shall not am Jay
any person In any manner so as to become subject to the Workers'Compensatlon Laws of Cell- All roofs,shall be inspected prior to any roofing materiaTheing
lornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOT CE TO APPLICANT: after makinbecome
subject t.the Worrkers'Compefnaetlon provisionis ofthelCatO LaborCode.you Cf must fo thwlltlh comply Applicant understands and will comply with all non point
with such provisions or this permit shalObe 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 coverings to b Class'C bett
herebyIse representatives of this city to enter upon the above-menllond property for In-
purr i
specimen purposes.
(We)agree to save,indemnlfy and keep harmless the City of Cupertino against liabilities,
judgments,costa and expenses which may In any way accrue against said City In consequence
—��
of the granting of this permit. ATURE OF APPEICANT DATE
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
nFRIrF r-I