R 4874 (2) PERMIT
APPLICATION FOR CITY of CUPERTINO NUMBER R' 4874
.
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
r
Q v� CGiL(.O RESIDENTIAL COMMERCIAL OTHER
OWNER'S /�'+�- -( ,0,4 1 HAZARDOUS FIRE AREA
C16
/ /! -� YES [:1II yes-I understand that a Class A
NAME " C D t c Y, iA Qn-.� ,.��Y1 root assembly is required.
✓� - lw &e`e �� NO X Initial , I.C.B.O.#
ADDRESS L%3II—G�A lIG7, /-0G Gj?'iD ?,� -aSS��z— EXISTING ROOF COVERING
PHONE 7 ✓ NUMBER OF EXISTING COVERINGS
CONTRACTOR
TO BE REMOVED TO BE RETAINED
NAME <
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP I 9Q /
OrS Q ( / / / EXISTING
PHONE
� BUILT-UP ROOF ❑ ,
LICENSE ❑
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION /
hereby affirm that I em Business
under erosions of Chapter 8(commencing with Section and WOOD SHAKES 7000)of of Divlelon 3 01 the Business end Professions Code,and my license is In lull force entl
effect
Liven Q 0 SHINGLES ❑
License Class� Llc.Number ��/�
Date �� Z Contractor Z 0 ER
� (SPECIFY) ❑
OWNER-BUILDERDECI.ARATI NPROPOSED
1 hereby affirm that I am exempt from the Contractor's License Law 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 El
for such permit to file a signed statement that he is licensed pursuant to the provisions
OI the Contractors License Law(Chapter S(commencing with Section 7000)of Division 3 of 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 applloan,for a permit subjects the applicant to
a civipenalty of not more than five hundred dosare glaoo).); WOOD SHAKES
El ,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 Code:The Contractors License Law dose 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 ❑ LT
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) ] �wS�Lcf�
not build or Improve for purpose of sale.). / \
❑1,as owner of the property,em exclusively contracting with licensed contractors to construct �d
the project(Sec.7044,Business and Professions Corte:The Contractors 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 License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B 8 P.C.for this reason
Owner oma
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury One of the following declaration:
❑I have and will maintain a Certificate 01 Consent to self-insure for Worker's Compensation, Building as provided for by Section 3700 of the Labor Code,for the performance of the work for which this /�/ 9�' gjnOu g /Q a
permit Is Issued. /L� O ✓�C Seismic
❑ have and will the pelrf Worker's Compensation Insurance,as required Is I by d.My
Worker's'of
s /
the Labor Code,for the performance of the work for which this permit la Issued.My Worker's r
Compe�ne%eti�n Insurance carrier end Policy number are: Tota
96
CarrlQrl (L n�m.r �� Policy N PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROMWORKERS'
COMPENSATION INSURANCE N.C.]gs� p
(This section need n0f be completed II the permit Is for one hundred dollars(5100)vroelM Q �Q E `{'
I certify that In the performance of the work for which this permit is Issued,I shell not employ
any person In any manner so as to become subject to the Workers'Compensatlon Laws pof Cell. � roofs shall be inspected prior to any roofing material being
lornle.
�PP(J(pee 29 talled. If a roof is installed without first obtaining an
Data Applicant II1I I� .inspection,I agree to remove all new materials for inspection.
NOTICE a APPLICANT: a cher making this f the
of Exemption,y°t�sftm bdp°��.�t.,,,Applicant understands and will comply with all non point
subject to the Workers Compena after
provisions of the cafe Code,you must t It m
with such provisions or this permit shell be deemed revoked. source 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 ominances and state laws relating to building construction,andI roof coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spectlon purposes. VZ
(We)agree to save,indemnity and keep harmless the City of Cupertino ap°Icon liabilities, _ L 7
judgments,come and permit. s which may In any way accrue against said Clry In consequence
of the granting of this permit. SIGNATURE OFAPPLICANT DATE
• 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