R 4855 (2)0
a
11
PERMIT R,
4855
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMITEXPIRATION
(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
�j 2-
RESIDENTIAL----- COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
VES E]If yes- I understand that a Class A
NAME—/4e
roof assembly is required.
NO Initial I.C.B.O. a
,/
�7 ���
EXISTING ROOF COVERING
ADDRESS S/ iL�
�r
PHONE
NUMBER OF EXISTING COVERINGS
/
CONTRACTOR'S t
NAME
TO BE REMOVED TO BE RETAINED
ADDRESS Z G t
TYPE OF ROOF COVERING
CIN
EXISTING
�k
PHONES L "'O�
BUILT-UP ROOF ❑
LICENSE !
NUMBER - b
ASPHALT SHINGLES ❑
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license is In lull force and
effect. r
.5 r -3 6
WOOD SHINGLES ❑
License Close Llc. Number
r i y'
6. �(o
Date ^ Cantreclor
OTHER (SPECIFY) f'❑
f9__;1
OWNER -BUILDER DEC N
I hereby affirm that am exempt fro the Contractors Llcenee L the following
PROPOSED 301996
or reason.
(Sac. 7031.5, Business and Profession. Code: Any city or count hlch requires a to
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PO
permit
construct, alter, improve, demolish, or repony structure, prlor to Ile Issuance, also requires the
applicant for such permit to file a signed ate s t that he le Ilcenaetl pursuant to the provisions
of the Contractor's License Law (Chapter a�gencinp with Section 7000) of Division 3 of the
BUILT-UP ROOF Q 11t�U
(;I i� fir V i Lrt
Business and Professions Code) or that hs pt iRerolrom and the basis for the alleged
ASPHALT SHINGLE$ El
exemption. Any violation of Section731 a PI licant for a permit subjects the applicant to
a civil penalty of not more than Ilveh dollars MEMO).):
❑I, esownerorthe Ioyeas
s
WOOD SHAKES /J
properry;�J�/B with wages as their sole compensation, will do
the work, and the strut k'ItnLAtyrltl ad or offered for Bele (Sec. 7044, Business and Profes-
sloneCode:TheCont cgn
a_se Law does not apply toes owner of property who builds or
❑
dOESGee
Improves thereon, and 'such work himself or through his own employees, provided that
such Improvements Mended
WOOD SHINGLES ❑
ara,n 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
not bulld or Improve for purpose of sole.).
OTHER (SPECIFY)
❑ I, as, owner of the property, am exclusively contracting with licensed contractors to construct
the project (Sec. 7044, Business and Professlons 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 connector(s) licensed pursuant to the Contractors License Law.
E]I em exempt under Sec. ,B 8 P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner Date
WORKER'S COMPENSATION DECLARATION
APPLICATION DATEI
VALUATION
PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑ I have and will maintain a Cerdllcate of Consent to sell -Insure for Worker's Compensation,
as, provided for by Section 3700 of the Labor Code, for the performance of the work for which this
7 7
Building
permit Is Issued,
C] haveand will melntelhWarkere Compeneellon Ina nce, es requlretl by Section 3700 0l
Labor Code, for the of they(ork for w h ihle Is Issued, My
Or Oct
$EISf111C
-the performance permit
Compare if nlnsurayc rrler end Pollgq}rymb r r
Total a
_Z.� O ��
r/ 7✓
carrier PoucyNo.
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEM ION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(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 or hick this permit Is Issued, I shall not am toy
In
any person any manner so se to becom euble ih ork, re' Compensation Laws of Cell-
fornla.
All roofs shall l5ennspected prior to any roo ing material being
J�lDela
installed. If a roof is installed without first obtaining an
• Apo llcant
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If, after making this Car) Ic to of Exemption, you should become
eublect to the Workers'Compensation provlelone of yie abar Code, you must forthwith comply
ds and will Comply with all non point
p y
with such provisions or this permit shafte tleema I ev rad.
I certify that I have read this application and stet etthe above Information Is correct, I agree
to comply with all city and county ordinances entl stale laws relating to building construction, andbe
clas " or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
MiLIC
spection purposes.
(We) agree to save, Indemnify and keep harmless, the City of Cupertino against liabilities,
judgments, coats and expenses which may In any way accrue against said City In Consequence
NT DATE
of the granting of Imo permit.
PRE -INSPECTION:
PLYWOOD:
N ROGRESS:
INSP. DATE
INSP. DATE
SP. 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