R 4786 (2) PERMIT R_ 4 7 8 6
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
V RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
,4j VES ❑ If yes—I understand that a Class A
NAME �./ roof assembly is required.
NO ❑ Initial I.C.B.O.N
ADDRESS
7 t S �J - EXISTING ROOF COVERING
PHONE
V'6 H 6 d y NUMBER OF EXISTING COVERINGS
CONTRACTOR'S JM
- I,-
NAME_J TO BE REMOVED TO BE RETAINED
ADDRESSw TYPE OF ROOF COVERING
CITY&ZIP O /fl C 1111 G M� `y
S X
PHONEA4 31 0 " D BUILT-UP ROOF ❑
LICENSE 11
NUMBER i ASPHALT SHINGLES ] \
LICENSED CONTRACTORS DECLARATION 3/
hereby affirm that I am licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and ❑ �/
effect WOOD SHINGLES ❑ `h6
License Class Llc.Number 66
1 (�, OTHER(SPECIFY) ❑
Date comreeror
OWNER-BUILDER DECLARATION VPROPOSED
I hereby affirm that I am exempt from the Contractors License I-Ow 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,priorto 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 Contractor$License Law(Chapter a(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than live hundred dollars($500).): WOOD SHAKES
C]1,as owner of the property,or my employees with wages as their sots compensation,will do ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes.
sions Code:The Contractor's License Law 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 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 contractor(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
E]I em exempt under Sec. ,B 8 P.C.for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: A
❑1 have and will maintain a Certificate of Consent to aelbinsure for Workers Compensation, Orf Buildin
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this "j g
permit Is Issued r
❑I have and will maintain Workers Compensation Insurance,as required by Section 3700 of lip B "Y4 O D Seismic
the Labor Code,for Ihe performance of the work for which this permit Is Issued.My Worker's iY/q
Compene§`(Ion Lir co carrla ntl Polic umber are: ryR 7 Total
Cerner J Policy No.112"1 y—q 5 Y LPERMIt A RIZATION T
CERTIFICATE OF EXEMPTION FROM WORKERS' 1
COMPENSATION INSURANCE N.C.❑ C
(This section need not be completed If the permit Is for one hundred dollars($100)or less.)
I certify that In the performance of the work for which this permit Is issued,I shall not employ
any person in any manner so as to become subject to the Workers'Compensation Laws of Call- All roofs shall be Inspected prior t0 bny rq6ting material being
fornix. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTecome
subject 2 the Workers'CompeE TO APPLICANT: nsation proiviafter sionis of the11Labor Code,yolu must fo thwlithocomply 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 the above Information Is correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof coverings to be cl S�"Cfter."
hereby authorize representatives of this city to enter upon the above-mentloned property for In-
spection purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against Ilebllitlae,
/ judgments,oats and expenses which may In any way accrue against said City In consequence
of the granting of this permit. SIGNATURE 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