R 4647 (2) W
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 4647
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
•
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
WI160 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
vL) RESIDENTIAL COMMERCIAL OTHER
OWNER'S 11Lp- I1 I 1 �j� �/� _ RDOUS FIRE AREA
NAME 44 9- N �'J H�'rti 0� VES ❑ If yes ss mbly is req that. Gass A
roof assembly is reghnred.
�f U ' N Initial LC.B.O.M
ADDRESS—2221J7� duPEklAn 4b EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP
EXISTING
PHONE BUILT-UP ROOF ❑JJg.�
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that l am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is In full tome and
effect.
W OD SHINGLES ❑
License Class LIc,Number
Date Convector
HER(SPECIFY) ❑
OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the lollowlng lesson.
(Sec.7031.5,Business and Professions Code: Any city or county which req ulrea a permit to
• appconlicant,orsuhprove,ermit to file demolish, air statement
eny mentrthat he Is licenseor to issuance,also requires the ONll-�U F tt-I
applicant for permit to lila (Chapter 9(comm that with
pursuant to the provisions
�`C81 C/._//l/r{.,1z.i
01 the an Prof License Lew)or that B(commencing with Section 7000)of for the 3 of the
ex
Business ptio entl violation of Code)or that he Is exempt therefrom and the su baste for the alleged AS ALT SHINGLE$
exemption.Any violation Of Section 7031.5 by any s($5 0t for a permit subjects the applicant to
e civil penalty Of not more than five hundred dollars
($500).):
❑l,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,Bualnesa and Profes.
alone Code:The Contractor's License Lew does not apply to an owner of property who builds or WOOD SHINGLES F-1Improves thereon,and who does such work himself or th rough his own employees,provided that
such Improvements are not intended or offered for Sale.II,however,the building or Improvement
Is sold within one year of completion,the owner-bulltlar.111 have the burden of proving that he did OTHER(SPECIFY) El bull r Improve for purpose of sale.).
,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 ccnvactor(S)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B a P.C.for this reason
Owner Data
WORK 'S COMPENSATION DECLARATION APPLICATION DATE 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 sell-Insure for Workers Compensation, ,4 " BUII
as provided for by Section 3700 of the Labor Code,for the performance of the work tar which this
CIN
permit Is Issued. ry� Seismic
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of VV /�//k
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's T 24 1995 �V Total '
Compensation Insurance carrier and Policy number aro: JJ
Carrier Policy No. `-'r (RERMITAUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need not be completed If the permit Is for one hundred dollars($100)or leas.)
I certify that In the performance of the work for Which this permit Is Issued,I shell not emolay
any parson In any manner so as to become subject to the Worksro'Compensatl0n Laws of Calb All roofs shall be inspected prior to any roofing material being
forme. 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: II,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Coda,you must forthwith comply PP. p y p
with such provlelone or this permit shaNbe deemed revoked. SOUfCe 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 haws relating to building construction,and All roof coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes. Y
(We)agree to save,Indemnify and keep harmless the City ai Cupertino against liabilities.
• of the gran costa and permit. which may in anY way accrue against aeltl City In con6equenas
of ins granting of this permit. SIGNATURE OF APPLIQI(NT 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY