R-4689 (2) PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 4689
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777.3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
. 1B DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS 1
2-'2-11CU
� RESIDENTIAl COMMERCIAL OTHER
OWNER' HAZARDOUS FIRE AREA
h YES ❑ If yes—I understand that a Class A
NAME /J root assembly is required.
..�- NO ❑ Initial I.C.B.O.#-
EXISTING ROOFER
ADDRESS
PHONE NUMBER OF EXISTING COVERINGS
CONTR R'
TO BE REMOVED TO BE RETAINED
NAME
ADDRES ? - TYPE OF ROOF COVERING
CITYAt - EXISTING
PHONE BUILT-UP ROOF ❑
CENSE
NUMBER i ( ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Wass and Professions Code,and my license Is In full force and
effect. WOOD SHINGLES ❑
License Class - Up.Numbeontractorr?�
OTHER(SPECIFY) ❑
Date -BUILDS
' NSR-BUILDER ATI N - PROPOSED ® P4
I hereby a Bu i nes m exempt from the Contractor's or roue Law for the followlnB r eon.
(Sec.
7031.5,Business and Professions Code: Any city Or county which requires a permit to � F�0 ^
construct,alter.Improve,demolish,or repair any structure,prior to its issuance,also requires the BUILT-UP 0 �e IElI
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions G
. of the Contractor's License Law(Chapter B(commencing with Section 7000)of Division 3 of the 9g�a n$
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SH4GLES ❑
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to AVN
a civil penalty o1 not more than five hundred dollars($500).): WOOD SHAKES Fy4vo �
❑I,as owner of the peopany,or my employees with wages as their sole compensation,will do
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes. �,r& -
slons Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES El Improves thereon,and who does such work himself or through his own employees,provided that
such improvements are not Intended or offered for sale.If,however,the building or Improvement
Is sold within one year of completion,life owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively Contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B$P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will me mein a Certificate of Consent to self-insure for Worker's Compensation, BUlldln
as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which this
permit is Issued.
❑I have and will maintain Worker's Comp ellon Insurance,as required by Section 3700 of I l �J elSA
_the r d ,for he erfor of thew k for which thle permit le issued.My Worker' ` \\\
Cam sell carr) entl Policy nu or are: l �y Total
Carrtier ` Police PERMIT AUTHO DAT
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0 ^
(This section need not be completed If the permit is for one huntlred dollars($100)or less.) L G
1 certify that In the performance of the work for which this permit Is Issued,('hall not employ
any person In any manner so as to become subject to the Workers'CompanaatIon Laws of Cell. All r0 hall Pe r1spTcled prior to any roofing material being
tomla. installed. If a root is installed without first obtaining an
Dale Applicant inspection,I agree to remove all new materials for inspection.
NOTsubject 10 the Workers'CompeCE TO APPLICANT: nsation provisionls of thecate of Labor Code Exemption,
mustforou rtthwithoecome
comply Applicant understands and will comply with all non point
with such provisions or this permit shalgbe deemed revoked, Source regulations.
I certify thou 1 have read this application and state that the above Information Is correct.)agree
to hereby authorize
zalle city prese Countyordinancesthis ces and ter u on the
to buildingned property
f and A 'rings lob sass" "or better.,
hereby authorize represantetives of this city to enter upon the above-mentioned property for In-
apache)purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, oux
judgments,costs and expenses which may In any way accrue against said City In consequence SIGNATURE OF APPLICANT DA E
of the 9rof this Permit.
PRE-INSPECTION:
ION: PLYWOOD: IN-PROGRESS:
INSP. DATEINSP. 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