R 4986 (2)�l
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OFFICE COPY
PERMIT R_ 4986
APPLICATION FOR CITY OF CUPERTINO NUMBER
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
\ADDRESSPre//�
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FIESIDENTII
LJ y
COMMERCIAL OTHER
OWNER'
HAZARDOUS FIRE AREA -
VES [:j It yes—I understand that a Class A
NAME -�
roof assembly is required.
❑ Initial I.C.B.O. e
elill,NO
`- L
EXISTING ROOF COVERING
ADDRESS
I
PHONE <- —
®
NUMBER OF EXISTING COVERINGS
CONTRACTO ,
C1_
NAME 7
TO dE REMOVED TO BE RETAINED
_AME
ADDRESS
TYPE OF ROOF COVERING
CITU 8 ZIP
EXISTING
PHONE �3
BUILT-UP ROOF
LICENSE
NUMBER
ASPHALT SHINGLES ❑
LIC CTORS DECLARATION
I hereby affirm the m licensed under provisions of Chapter B (commencing with Section
WOOD SHAKES
7000) of DII1 3 otrSB elneee entl Profeeelona Code, and my license Is In lull tome and
effect.
License Claes t Lic, Number �1
�1�7 ��O
WOOD SHINGLES
�
OTHER (SPECIFY) ❑
Date Contractor
OWNER -BUILDER c RAD
1 hereby estrus that em exempt from the ore License Lew for the remitto
9
PROPOSED
e: Any line a
(Seccons. 70315, Business and demolish, or rep Code: Any city or count' which requires a permit to
to lesuence, alwrequires the
asigned
prior
BUILT-UP ROOF
applicant such permit Ills a Signed statement that license
applicunLalter,Improve, to file statair eny ment that Is licensed ofto the provisions
tr
of the ss an Contractors License Lew (cornet B is ex a
a 7000) the
with Section 7000) of for
3 le
,% the belle for
entl Proleeslone Code) or that he le exempt tans
and the ed
pt the
ASPHALT SHINGLES ❑
exemption. for t0
exemption. Any violation of Section hand a by any applicant br a permit subjects the applicant to
applicant
e civil penalty of not more then live hundred dollen
with wage
❑I,ea owner ofthe property, doyesewith wagee aetheir sale compensation,welltlo
WOOD SHAKES ❑
the work, end the structure le not
t Intended for mala (Sea Business and Prolee-
ores
sLaw not owner of t or
Improves thereon, end who does such work
Improsons Cotle: The, and who d license Lew does s not apply to an owner of property who pbul rovided
or his own employees, provided that
WOOD SHINGLES ❑
such Improvements
ears not edforf . If, how
thogenetlbrleer.illhowever, the building Improvement
lesold yearplatin, pros
OTHER (SPECIFY) ❑
tbuild or prove forpurposetofstheownerbulltlerwlllhavetheburtlenalprovingthathetlltl
not bulla or Improve for purpose of sale.)
❑ I, as owner of the property, mm exclusively contracting with licensed contractors t0 construct
the project (See. 7044, Business and Professions Code: 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 contractor(a) licensed pursuant to the Contractors License Lew.
❑ I am exempt under Sec. ,B S P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner Date
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 of Consent to self -insure for Worker's Compensation,
�'� L'
Building
ae provided for by Section 3700 of the Labor Code, for the performance of the work for which this
permit Is Issued
"7 -7
4
/ ��
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section 3700 of
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Seismic _45-0
the Labor Code, for the performance of the work r which this permit to Issued. My Worker's
Compense I Buren c rear en ynumb are:
Q p/�
Total sa `7s
terser Poll y N . ' l
PERMIT AUTHORIZATION
DATE
CERT KATE OF EXEMPTI FROM WORKERS'
COMPENSATION INSURANCE NAI]
(Tele section neednot be completed If the permit Is for one huntlmtl less.)
the of me work for which this permit Is issued, shall not employ
sued, I shall($100)not
certify them thinner as
All roofs shall be inspected prior to any roofing material being
so to
any person in any manner so as m bosoms Subject to ma Workers' Compensation Laws m cen�
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
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
Applicant understands and will comply with all non point
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 le correct. I agree
to comply with all city and county ordinances and State laws relating to building construction, and
All roof coverings to be Cl °Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
n /
Y?
epection purposes.
t _`
(We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities,
judggents, coats and expenses which may In any way seems agea Bald City In sone ---encs
/
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SIGNATURE OF APPLICANT DATE
of t e granting of INS permit,
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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY