R 4946 (2) PERMIT R_ 4 9 4 6
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 ADDRESS ,L�/T h
0Z 1\/_1 O RESIDENTIAL COMMERCIAL OTHER
OWNER'S t HAZARDOUS FIRE AREA
NAME-51 � YES h000f assembly is reG'hello Class A
e' NO Initial I.C.B.O.k
ADDRESS S J O EXISTING ROOF COVERING
PHONE
Y,a g ` L S S O NUMBER OF EXISTING COVERINGS '
1_�1 CONTRACTOR'S I t S I1 A `I1
�pp
TO BE REMOVED �—TO BE RETAINED
NAME N � o
ADDRESS CITY a ZIP- �S S O S/ 1 N ( P S� tIV�a S TYPE OF ROOF COVERING
ry EXISTING
/,
PHONE y 6 r� �' C? o BUILT-UP ROOF ❑
LICENSE 76-S-
NUMBER 7 6 S 7 l ASPHALT SHINGLES El
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter g(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,end my license le In full force and
effect. (' y Q S p WOOD SHINGLES ❑
License Claes ` LIc.Numr be
Date 2 Q Contrector Mrs t� OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or ounty whlch requires a permit to
construct,alter,Improve,demolish,or re palrenyaMucture,prI It J@@euence,aleorequlrsethe BUILT-UP ROOF ❑
apPlicent for such permit to file a elghad ec.t:m.nt that ha_I,Ute tl p reuent to the provlllone
of the Contractors License Lew(Chapter B(commenU with S o 00)of DIvison 3 of the
• Business and Professions Code)or that he is ex�grlfp1 ate I)<t he beets for the alleged ASPHALT SHINGLES
exemption.Any violation o1 Section 7031.5 t eppyepbl1 rmit an
the applicant to
a civil penalty of not more than live huntlretl tl7o8are� 60)
❑I,as owner of the property,or my amp as se a their Iola compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intends r 1Q 7 eels(Sec.7044,Business and Poles.
If
The Contractor's License Law n7ft'apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,end who does such work If or through his own employees,provitletl that ❑
such Improvements are not Intended or offers 'for sale,It,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) ❑
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.704,Business and Professions Code:The Contractors License Low 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 contrector(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
E]I am exempt under Sec. ,B 8 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the fallowing declaration:
❑1 have and will maintain a Certificate of Consent to sell-Insure for Workers Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this g
.. permit Is Issued. Seismic `�
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 o/
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's ���
Compensation Insurance csill "ntl Polis n9mb�r ere: 24 Total
p S f Ate T U f�f d I y �-J RO 9 S PERMIT AUTHORIZATION DATE
Cartier. Polley No.
CERTIFICATE EN EXEMPTION FROM WORKERS' 7// v.rte, yr v r u�r W.V C]./�
COMPENSATION INSURANCE N00)o _
(This section need not be completed If the permit Is for one huntlretl dollen($100)or leas.) -
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 become subject to the Workers'Compensation Laws of Can- All roofs shall be inspected prior to any roofing mat rial being
fornla. 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 sort
subject to the Workers'Compensation provisions of the Labor Cade,you must forthwith comply PP ply 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 correct.I agree
to comply with ell city and county ordinances and state laws relating to building construction,and All roof coverings to be class"C"or better.
hereby authorize representahl oe of this city to enter upon the above-mentlonad property for In- /
erection purposes.
(We)agree to ends,Indemnlly and keep harmless the City ai Cupertino against Ilabllltn a 4 7
futlgmenta,costa antl expanaee which may In any way accrue agelnel aeltl Clty Inconsequence
• otiRagranting ofthis permit. I NATURE 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