R-4559 (2) PE
APPLICATION FOR CITY OF CUPERTINO
NUBER R- 4 5.5 9 .
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
/ YES ❑ It yes—I understand that a Class A
NAME roof assembly is required.
NO Inihal I.C.B.O.#
ADDRESS_Y2 EXISTING ROOF COVERING
PHONE _,>1 — Q NUMBER OF EXISTING COVERINGS v —
CONTRACTORI'S'T {/�� /'
Jar/ y T ,R .) /A /p /\6 UTA/1f J•�d Y/�P TO BE REMOVED TO BE RETAINED
NAME
ADDRESS�� / _5_70—t
� l--r TYPE OF ROOF COVERING
CITY a ZIP l J� e✓ EXISTING
�.) S20 N Td s e_ civ q s'//e
PHONE Icy — 1�n BUILT-UP ROOF ❑
LICENSE 47 ASPHALT SHINGLES
NUMBER oC X.
LICENSED CO TRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 0(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and
effect. WOOD SHINGLES ❑
License Class Lic,Number
Date Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
1 hereby affirm that I am exempt from the Contractor's License Lew 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,prior to 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's license Law(Chapter B(commencing with Section 7000)of Division 3 of the th
Business and Professions Code)or that he Is exempt therefrom and the basis for e 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 five hundred dollars($500).): WOOD SHAKES ❑
01,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-
sions Cotle: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.).
01,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 Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
01 am exempt under Sec. .B 8 P.C.for this reason
Owner Date APPLICANdNi-DATE VALUATION PE MIT
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, SFP . 9985 / i.04v cfe Build
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this J/CJ_/�
permit is Issued. r+ 70
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of C1 l Y Ur Seismic
the Labor Code,for the performance of the work for which this permit Is Issuetl,My Workers
Compensation Insurance carrier and policy number are: NU Total
Carrier Policy No. PERMIT AUTHORIZATION D.#T E
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.Q
(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 or which this permit Is Issued,I shell not employ Lis
any person In any manner so as to become subject to the Workers'Compensation Laws of Cali- All roofs sMall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
TO APPLICANT: become
subject toEthe Workers'Compefnsation provisionis of thei"bar Code,cate yoiu must fo thwof Exemoullth comply Applicant understands and will comply with all non point
with such provisions or this permit shellibe doomed revoked. source regulations.
I certify that I have read this application and state that the above Information Is correct.)agree
to comply with all city and county ordinances and state laws relating to building construction,and Ill coverinpecla: or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In. /
speedos purposes
(Wa)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, �
• judgments,costs and expenses which may In any way accrue against said OR,in consequence SIGNATURE OF APPLICANT DATE
of the granting 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