R 4948 (2) APPLICATION FOR CITY OF CUPERTINO PERMIT
U BER R- 4948
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(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 �
L O •� �• ��`�"^� � RESIDENTIAL /
COMMERCIAL OTHER
owNEHAZARDOUS FIRE AREA
VES ❑ II as-1 understand that a Class A
NAME 'e— of
assembly is required.
NO Inifli I.C.B.O.g
ADDRESS ( EXISTING ROOF COVERING
PHONE d — �O NUMBER OF EXISTING COVERINGS
CONTRACTORS
NAME O 5 (3 \ � o., TO BE REMOVED TO BE RETAINED
ADDRESS--Z lL�\�\ \�(� V1r� TYPE OF ROOF COVERING
�� u a�_k _Wki EXISTING
PHONE BUILT-UP ROOF
NUMBEE ��� ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES ❑ '
7000)of Division 3 of the Business and Professions Code,(and n,/my license is In full force and
51!19
Jp
effect. 7 1
WOOD SHINGLES ❑
License Class Llc.Number
—1 � O ❑
Date Contractor OTHER(SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from the Contractors License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct.altar,Improve,cambium,or repair any structure,prior t issuance.also requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he is lice a pursuant to the provisions
of the Contractor's License Lew(Chapter 8(commanclng with Sec 7000)of Division 3 of the
• Business and Professions Cade)or that he Is exempt therefrom d;bgsls for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant r is the applicant to
a civil penalty of not more than five hundred dollars($5Q0)':;:
E)1,as owner of the property,or my employees w t wag It compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or off d for 6 ac)a44,Business and Profes.
slons Code:The Contractors License Law oo Wap n ner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work hl 0 o gb Bl3 own employees,provided that ❑
such Improvements are not Intended or ofle ylle.IIS a waver,the building or Improvement
Is sold within one year of completion,the r-bu 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 contractorls)licensed pursuant to the Contractor's License Law.
L] B P. PROVIDE MFGR.INSTALLATION SPECS.
I am exempt under Sec. ,B C.for this reason
owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penally of perjury one of the following declaration: /I1 1
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, V vN 8 0nze� Buildingt`q
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this /J`,
permit is issued. �j�
❑1 have and will maintain Workers C mpensation Insurance,as required by Section 3700 of ( !r r Uh (, �- Seismic "70
the Labor Code,for the performance of a work for which this permit Is Issued.My Worker's UI'er{l(�l `\7. q
Compens Insurancece rand Poll number are: � Total ?6
carder U Policy No. OO" •2,01 PERMIT AUTHORIZATION DATE
CERTIFICATE EX MPFROM WORKERS'
COMPENSATION INSURANCE 1.0, o
(Thio section need not be completed If the permit le for one hundred Dollars($100))or leas.) \r/`
1 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'Compensation Laws of Can- All roofs 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 TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and will Comply with all non Dint
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP P y p
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 correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,and r cove IO 0 CIBSS"C"Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for Im
spectJon purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
judgments,costs antl expenses which may In any way accrue against said City In consequence
of the granting of thls permit. S TORE OF APPLICANT 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