R-4898 (2) PERMIT R_ 4898
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
^� REROOF PERMIT (408)777-3228PERMIT EXPIRES IF WORK IS NOT
WITHIN 180 DAYS OF PERMITT ISSUANCESUANCE ED
OR
1BO DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
ioilkf W O RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME L — S O roof assembly is required.
NO Inibi I.C.B.O.H
ADDRESS nM �E/6 EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS
PHONE
CONTRACT �S_�
TO BE REMOVED ( TO BE RETAINED
NAME D ti
'' ADDRESS l�. �^ s• � \ eye psl� TYPE OF ROOF COVERING
4 clrva'IP 1 J ( XISTING EXPIRE®
PHONE l 0� J �b BUILT-UP ROOF ❑
LICENSE
NUMBER zilIt ASPHALT SHINGLES 11LICENSED CONTRACTORS DECLARATION
I h
hereby affirm that I em Business
under Professions
loss of Chapter y(commencing calif Section WOOD SHAKES
7000)of Division 3 of the Buelnese end Professions Code,and my license Is In full force and r\
effect.
WOOD SHINGLES ❑
License Clas Lic.Numb �'' Q?7 r
OTHER(SPECIFY) ❑ Q
Date Contra or / � J
OWNERBUILDER ON P ED \� O
I here alfirm het am exempt from Iha Cont cfor's icense Law for the following reason. G1-
(Sec.7031.5,Buelnese and Prolaealons Code: A k or county which requires a permit to �$._,Y s,
onstruct,alter,improve,demolish,orrepair any structure,prior to its issuance,also requireslhe BUIL ROOF Yl`I
applicant tar such permit to Ilia a signed statement that he Is licensed pursuant to iha Provisions �`� J
of the Contractor's License Lew(Chapter B(commencing with Section 7000)of Division 3 of the5�4J
Business and Professions Coda)or that he Is exempt therefrom and the bells for the alleged � LT SHI GLES
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).): W D IAKE6 ❑
❑I,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 Profes-
sionsCode:The Contractor's License Law does not apply to an owner of property who Wilds or WOOD SHINGLES El
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-Wilder will have the burden of proving that he did OTHER(SPECIFY) - ® CP�Lxe100�
not build or improve for purpose o1 sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sac.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 Wilds or improves thereon,and who contracts for such projects
with a contractors)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR. INSTALLATION SPECS.
`71 am exempt under Sec. ,B&P C.for this reason
Owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty o1 perjury one of the following declaration: _ - ! _Q
I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, BUlldmg
as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which this ,r/ ZO n/ �� a 00 .
permit is Issued. .7 —14p b Seismic 70
it have and will maintain Worker's Compensation Insurance,as required by Section 3700 01
the Labor Cade,for the performance of the work for which this permit Is issued,My Worker's
Com eneeU�oo In(`s�u�ran(,e crr((iff�,,�r..��,�� tl Po l number ere: l/ Total /Z-7 7 0
Carrier e \"rK�� PolicyNo.7lry z)4f--4�g- PERMIT AUTHORIZATION DATE
' CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed If the permit is for One hundred dollars($100)or less.) C/ 2 Q� 9 `
I certify that In the performance of the work Ior kJSJssued.I shall not employ .45
any person I anyma nor so as to bec0 lett to the Worker penes on ws of Cali. All roofs shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date JN a Ap - inspection,I agree to remove all new materials for inspection.
subject to he Workers'Compensation risk ng
no of aboy Code,yolu mustufothwlithcecome
comply Applicant understands and will comply with all non point
with such provisions or this permit shall be de ed r ked. SOUr
I tartly that l have read this application and at het the above Information Is correct.)agree
tocomply with all city and county ordinances and state laws relating to WIIk1Ingconsiructlon,entl All r00})Everi to CIas O atter.
hereby authorize representatives of this city to enter upon the above-mention, property for In-
apecilon purposes.
(We)agree to save,indemnify end keep harmless the Cly o1 Cupertino y In consequence
llebllen e. ZZ, 96
judgments,,coats and expenses which may In any way accrue against eeltl City In consaquenca SIG URE F_APPLICANT AT
of the pmntlnp of this permit.
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