R 4830 (2) PERMIT R_ 4830
APPLICATION FOR CITY OF CUPERTINO NUMBER
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 UST CALLED INSPECTION.
BUILDING ADDRESS
GRESIDENTIAL COMMERCIAL OTHER
OWNER'S . HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME `�4 V�J roof assembly is required.
NO Initial I.C.B.O.k
ADDRESS ^ c EXISTING ROOF COVERING
PHONE !/7NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
w. .
NAME ♦ � TO BE REMOVED TO BE RETAINED
[/�7.�
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP EXISTING
PHONE BUILT-UP ROOF ❑ \
LICENSE
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Profession$Code,and my license is In full force and
effem
WOOD SHINGLES ❑
License Class LIc.Number
Date Contractor
OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
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,or 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
of the Contractors License Law(Chapter g(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he Is exempt therefrom and the basis for the applicant
to ASPHALT SHINGLES
Busies Any violation of Section 7031.5 by any applicant for a permit subjects basis
applicantto
a civil penalty of not more than five hundred dollars($501 WOOD SHAKES
E]1,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 Profen
sions 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 ownerbullder will have the burden of proving that he did OTHER(SPECIFY) ❑
nal b Ild or Improve for purpose of sale.).
I,ee owner of the property,am exclusively conirecling with licensed contractors to construct
th p ca(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
e ply to an owner of property who builds or improves thereon,and who contracts for such projects
with a contrectona)licensed pursuant to the Contractor's License Law, PROVIDE MFGR.INSTALLATION SPECS.
❑1 am ex pl under Sec. ,B 8 P.C.for this reason
DoleWORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: ppi�ss
❑ have and will maintain a Certificate of Consent to Performa for Worker's Compensation, Y' I BUlldln
as provided for by Section 3700 of the Labor Code,for the performance of Worker's
work for which this g
permit Is Issued. $eISn11C
C]I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of n/yn � J
the Labor Code,for the performance of the work for which this permit Is issued.My Worker's IWA j 19%'-� (nl Total
Compensation Insurance carrier and Policy number are:
Carrier Policy No. if T RERMITAUT1,jORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑ 2
(This section need not be completed If the permit Ie for one hundred dollars($100)or less.) l I
I certify that In the performance of the work for which this permit Is Issued,I shall not employ
72
any person in any manner so as to become subject to the Workers'Compensation Laws of Cali. All roots shall be inspected prior to any Doing m teri b
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
subject to thTICE eOWorkeres'Compensation proviafter sions ofetheflcate of Laborr Codemyou must la thwlltlbecome
h 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 tae above Information Is correct.)agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof cover gs to be class"C"or better. I $
herebyauthorize purposes.representatives of this city to enter upon the above mentioned property for Im Idly c?� I IJ
her etlon purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
\ judamenta,cost$antl expenses which may in any way accrue against said City In consequence
onhe granting onh permit, SI TURE OF APPLICANT 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
OFFICE COPY