R 4100 (2) OMBERRazzRMIT
APPLICATION FOR CITY OF CUPERTINO 4100
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 WITHIN 1180 DAYS OF PERMIT NOT
OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING.ADDRESSr BUILDING USE
1
IOve'v �V LL 4 RESIDENTIAL COMMERCIAL OTHER
OWNER'S / �j�. /
ROOF
NAME �iNDA X/INdL/C� FIREARDOUS COVERING
AREA
ADDRESS EXISTING ROOF COVERING
��
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTO
TO BE REMOVED TO BE RETAINED
NAME �- TYPE OF ROOF COVERING
CITY ADDRESS
IITh EXISTING
PHONE BUILT-UP ROOF
LICENSE AS
NUMBER
WOOD SHAKES
LICENSED CONTRACTORS under DECLARATION
I hereby affirm that am Ilcmud under provision.101 Chepbr B comment
zing wHh Election 70001 of Divl$lon 3 of the Business and Profession.Code, INGLES
and my license is In full force and affect.
License Ctap Lic.Number
Dau Contractor OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for PROPOSED
the following reason. (Sec. 7031,5, Business and Profession.Coda: Any city
or county which require$ a permit to construct, alter, Improve, dem.li$h,or
repair any structure, prior to its issuance, also requbn theapplicantfor.uch J
Pon. to file a signed statement that he is licensed pursuant to the provisions BUILT-UP ROOF
of Me Contractor's License Law (Chapter 9 (commencing with Section 7000)
of Division 3 of the Business and Profissiont Code)or that he is exempt there ASpHA
from and the anis for the alleged exemption. Any violation of Section
7031.8 by any t five hu lore permit mbjacts the applicant to•civil penalty
of not mon that five the pro Golfers ff6y em DDD.SHAKES
❑ I, ti owner of the property,or he employees with wenn a.their Sola
compmeation,will do tM1a work, and the structure ro Is not intend'a'or 0fleratl
for sale (Sec. 7144, Business end Profusions Code: The Contractor's License OD SH INGLES
Lew don not apply to on owner of property who builds or improve'thereon,
snd who don.0 ch work himself or through his own employees,provided the,
such Improvement ere not intended o offered for seta. If, however, the OTHER ECIFY)
building or improvement is sold within res one year of completion, the owner
builder will have the burden of proving that he did not build or improve for
puroop.f sela')' PROVIDE I.C.B.O. REPORT NO.
❑ I, at owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professions
Code: The Contractor's License LAW do..not apply toanowner ofproperty pROVIDEMFGR. INSTALLATIONSPECS.
who builds or improve. thersun, and who contract for such project with a
contrector(s)licensed pursuant to the Contractor's License Law.
❑ 1 am exempt under Sec. ,B.&P.C.for this
r...on APPLICATION DATE VALUATION PERMITEEE
Owner Data
WORKERS'COMPENSATION DECLARATION0 BuildingOIL
I hre
eby affirm that I have a certificate of consent to self-imm�,or
.car
tifi[at of Workers'Compensation Insurance,Or a certified copy thereof 1$N. v.qO
38100, Lab.CO. V 1 Seismic
Policy No. Company
8 T;r3GE
Certified copy is hereby furnished. W/i ` `s �n� �� /'��t T018I
Certified copy is filed with tate city inspection division. �-
Applicmt
CERTIFICATE OF
FEXEMPTIION RANOM WORKERS' N.C.
C, 0 H RMIT AUTHORIZATION DATE
COMPENSATION(This section nntl not be completed if the permit is for one hundred dol
Ins(5100)or Ins.) lye'�✓
I certify that the performance of the wank for whlcM1 this permit is
'mm ad, I shell not employ any parson In any manner m a.to become subject
to the Workeri Compensation Laws of California.
Data Applicant
NOTICE TO APPLICANT: If, alter making this Certificate of Exemption,
Veru should bacams subject to the Workeri Compensation provision,of the
Labor Code, you mean forthwith comply with such provpions or this permit
shall be domed revoked. All roofs shall be inspected prlortoany roofing material being
I certify that I have read this application and seta that the above informs Installed If a roof is Installed without first twining an
lion is correct. I tons to comply with all city and county ordinances and Inspection.I agree to remove all new mat MATE
.
fatatete law. relating to bullring the
above
end ne Pr authorize nprnac. p err g I`/'l,
purpoof this city to enter upon the ebovsmemloned property for Inspection
purpose.
(We) porn to eve, Indemnify and keep harmless the City of Cupertino
.p!mt liabilities,Judgments,Costs and expenses Which may in anY way.C[rUs
again.'void City in consequence of the granting of this permit. SIGNATOR OF APPL ANT
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
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