R 4984 (2) APPLICATION FOR CITY OF CUPERTINO NUMBER R- 4984
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
D�l /1/V/W� '/•`I � i RESIDENTIAL COMMERCIAL OTHER
ER'S
OWNHAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME roof assembly is required.
NO Initial I.C.S.O.W
ADOR8 /• [�C. EXISTING ROOF COVERING
PHONE
` I • w' NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
r TO BE REMOVED TO BE RETAINED
NAME
ADDRESS O /t F R60F COVERING
CITU ZIP
w +G
PHONE IQz"� / BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter a(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 Claes Lic.Number
Data Contractor
OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's cense Law for this following reason.
(Sec.7031.5,Business and Professions Code: Any city gpnty which requires a permit to
construct alter,Improve,demolish,or repair any structure,p t tp Its Issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that het Sed pursuant to the provisions
of the Contractor's License Law(Chapter a(cpr
l n 7000)of Division 3 of the
• Business and Professions Code)or that he Ir antl the basis far the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by qc permit subjects the applicant to
e civil penalty of not more then Ilve hu tlr❑I,asowneroflhepnperryor es as their sole compensation,will do WOOD SHAKES ❑
the work,antl the structure IB rR�qqL e r o1Wedd for sale(See.7044,Business and Praise.
alone Cod e:TheContraoofe{Ica Law,does not apply to an owner of property who buildsor WOOD SHINGLES
Improves thereon,antl who ddSS�te ca. ik himself or throughhla own employees,provided that ❑
Such Improvements are not Intaudad or offered for sale.It,however,he 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 bunds or Improves thereon,and who contracts for such projects
with a contractor(s)licensed pur uant to the Contractor's License Law.
I e axPROVIDE MFGR.INSTALLATION SP
e pt er S c a&P.C.for this reason
40 4001
�Uld.lp,
Date APPLICATION DATE VALUATIO PERMIT FEE
ER'S COMPENSATION DECLARATION
1 Hereby a irmf pedury ane al he following declaration:
❑I have antl ertificate of Consent to aelbinsure for Worker's Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work Mr which thle JUL. 15 1996 g
permit Is Issued. JJ el
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
the Labor Code,for the performance of the work for which this permit is Issued.My Workers CI1 Ut GUf tfS l I IK_/
Compensation Insurance carrier and Policy number are: NU Total
Carrier Policy No. PERMITAUTHORIZATIONDATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANC /
N.C.❑
(This section need not be completed if the permit Is for one hundred dollars($100)or lees.) `
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 becoma subject to he Workers'campensadon Laws of Cali. All roots shall 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.
NOTICE APPLICANT. should
subject to theOWorrkers'Compefnsation proaltarlvisionls of theiLaborr Code,cate yoof Exemlu mustufo th
hwi eecome comply 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 correctI agree
to comply with all city and county ordinances and state Tawe relating to building conatraclion,antl Il to 0 e fs b class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spectlon purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
judgmenta,coats and expenses which may in any way accrue against said City In oneequence
• of the granting of this permit. 51GIVATURE OF AP PLICA NTI rOATE
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