R-4501 (2) APPLICATION FOR CITY OF CUPERTINO
NUMB PERMIT 4501
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
P4
RESIDENTIAL � COMMERCIAL OTHER
OWNER'S n HAZARDOUS FIRE AREA
/rA YES [:] If yes-I understand that a Class A
NAME— root assembly is required.
NO ❑ Initial I.C.B.O.»
ADDRESS S —�' EXISTING ROOF COVERING
PHONE ;2,S -2—'— Z NUMBER OF EXISTING COVERINGS '
CONTRACTOR'$ , /J
NAME •] _ _f'/1{ n �,`(/��/q TO BE REMOVED TO BE RETAINED
ADDRESS /�/0 TYPE OF ROOF COVERING
CITY s ZIP �p, /, p^'r
EXISTING
PHONE "141-0 BUILT-UP ROOFLICENSE
❑
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ❑
700 0)of Division 3 of the Business and Professions Code,and my license Is In full force and
affect.
/� WOOD SHINGLES ❑
License Claes ` Lic.Number 4 6 6 6 8
OTHER(SPECIFY) ❑
Date 0/11"l Contrecto
OwNER-BUILDERDEC RATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Lew far 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 - (ts•f/`W
' of the Contractor's License Lew(Chapter 9(commencing with Section]000)of DNision 3 01 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
e civil penalty of not more than five hundred dollars($500).):
C]1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sec.704,Business and Profes-
sions Code:The Contractor's License Lew does not apply to an owner of property who bultds or WOODSHINGLES 13Improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for sale.ll,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 contractors)licensed pursuant to the Contractors Lic ens a Law. PROVIDE MFGR.INSTALLATION SPECS.
C]I am exempt under Sec. ,B&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 Workers Compensation, Oct Building 96.00
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this ',/� /
permit is Issued. �<7 u �4
E]I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of Seismic •6�
the Labor Code,for the performance of the work for which this permit Is issued.My Workers
-Compensation Insurance carrier and Policy number are: Total 6.60
Carrier �o Policy No.pu/o 2-65197. PERMIT AUTHORIZATION DATE
CERTIFICATE EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed If the permit Is for one hundred dollars($100)or less.) 4Q ri `(f• ZS-C�
1 certify that In the performance of the work for which this permit is Issued, shell not employ '
any person In any manner so as to become subject to the Workers'Componsi All roof^shall be inspected prior to any roofing material being
fertile' installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: 11,after makinthisoshoul
subject to the Worrkers'Compensedon provisions of thteiLabor Code,cate you of must othwitlhbecome comply Applicant understands and will comply with all non point
with such provisions or this permit shalQbe deemed revoked, SOUTCe 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 roofco enng be Class"C•"Or better
hereby authorize representatives of this city to enter upon the above-mentioned property for in. t,; /J /�
hereby
purposes �I�(M,`// Q
(We)agree to save.Indemnify and keep harmless the City of Cupertino against liabilities, - S
judgments,costs and expenses which mey In any way accrue against said City In consequence
• of the granting of this permit. SIGNATURE F APPLICANT /�
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DAF
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE INSP. DATE INSP. CIIY UI- WYtDATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY