R-4610 (2) PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 4 610
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (406) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
• WITHIN 180 DAYS OF PERMIT ISSUANCE OR
BUILDING ADDRESS
180 DAYS FROM LAST CALLED INSPECTION.
3 1 RESIDENTIAL_!! OTHER
O ER'SHAZARDOUS FIRE AREA
%
,w YES ❑ If yes—I understand that a Class A
NAME_ nodi assembly is required.
NO Initial I.C.B.O.k
ADDRESSYL I 4 EXISTING ROOF COVERING
PHONE O NUMBER OF EXISTING COVERINGS /
CONTRACT R'
N. TO BE REMOVED TO BE RETAINED
NAME
ADDRESSZ \ TYPE OF ROOF COVERING
CITY&ZIP A
EXISTING
PHONE -2— -,] ��''� BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES
LI N D CTORS DECLARATION
hereby affirm that I em licensed r provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the cosiness and ntl Professions Code,and my license Is In full lone and
effect.
reWOOD SHINGLES ❑
License Cle Liu Number T.
OTHER(SPECIFY) 11Data 2.a Contractor
OWNER-BUILDER DECLARA N PROPOSED
I 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.after.improve,demolish,or repair any structure,prior to its issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to lila a signed statement that he Is licensed pursuant to the provisions
. of the Contractor'sdlcense Law(Chapter 9(commencing with Section 7000)of Division 3 of the '
Business end,:my
fesslons Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES it
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of not more than five hundred dollars($500).):
I,as owner of WOOD SHAKEShe 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 Profes.
sions Code:The Contractors License Law does not apply to an owner of property who builds or
Improves thereon,and who does such work himself or through his own employees,provided that WOOD SHINGLES ❑
such improvements are not Intended or offered for sale.11,however,the building or Improvement
Is sold within one year of completion,the 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 Lew 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 contractor(s)licensed pursuant to the Contractors License Law, PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
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 Worker's Compensation, p Building
as provided for by Section 3700 of the Labor Code,for performance of the work for which this W
permit is Issued. r
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 ofs /*SBISfnIC
' the Labor Coda,for the performance of[h work for which this permit is Issued.My Workers f �y
Compensation s ancec rr Brand Pollc number are: 4 '4 / O Total
Cards Policy No. (1-(,Li/,PERMIT AUT N DAT
C RTIFICATE F EXEMPTION FROM WORKERS' �„r
COMP NSATION INSURANCE N.C. rl
(This section need not be completed if the permit is for one hundred dopers($100)or less.)
I certify that In the performance of the work for which this pe mit ie issued,I shall no,employ
any person in any manner so as to become ruble the war ,rS'Compensation Lev of cat- All roofs shall a inspected prior to a rooting m erial sing
forms, c V installed. If a roof is installed without first obtaining an
Date��I ` plmar inspection,I agree to remove all new materials for inspection.
NOTICE O APPLICANT: If,after making t artificers of Exemption,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensation provi sof the Labor Cods,you must forthwith comply P Y P
with such provisions or this permit shell be 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 vermgs be as 'Gil'or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes. ( ie `
(We)agree s save,indemnity and keep harmless the City el Cupertino against liabilities,
• jutlgmemn costs and expanses which may In any way accrue a9alnat said City in consequence
of the granting of this permit SIG RE OF APPLICA T 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