R-4712 (2) L) r2
[NUMBPERAPPLICATION FOR CITY OF CUPERTINO
IER R- 471
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
S
WITHIN DAYS PERMIT ISSUANCE OR
WI DANSS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
L� 26zofl�_4"— el RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES If yes—I undersand that a CI. A
NAME roof assembly is required.
r �/ �` NO Initial I.C.B.O.K
ADDRESS , )�� -e/,"w 11—
�/`� / EXISTING ROOF COVERING
PHONE Z (� NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S AA
TO BE REMOVED Z TO BE RETAINED
NAME
ADDRESS
/�/C'/� /�J�� TYPE OF ROOF COVERING
iJ �`�
clnazlP /!�/ G , EXISTING
PHONE � �/ / 7 BUILT-UP ROOF ❑
CENSE
NUMBER S � J� b 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 Buslnass no Professions Code,and my license is In full force and
affect. WOOD SHINGLES ❑
License Class "'' Lic.Number
Date L ' S C.h for OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATI PROPOSED
I hereby a Irm that I am exempt from the Contractor's Lic a Lew for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or curry which requires a permit to n A
construct,altar,improve,demolish,or repair any structure, or to Its Issuance,also requires the BUILT-UP ROOF O`L'{],
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions C�T� ,(
• of the Contractors License Lew(Chapter B(commencing with Section 7000)of Division 3 of the 'Y
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES Gj ❑
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to L �9y,
a civil penalty of not more than five hundred dollars 1$500).):
IZNN-
0 1,as owner of the property,or my employees with wages as their sole compensetlon,will tlo L
the work,and the structure is not intended or offered for sale(Sec.7044,Business and Proles-
QQD SHAKES ❑
alone Code:The Contractors License Law does not apply to an owner of property who builds or QQD SHINGLES ❑
Improves thereon,and ho does such work himself or through his awn employee.,provided Ihal
such Improvements are not Intended or offered for sale.II,however,the building or Improvement
Its oltl within one year of completion,the owner-builder will have the human of proving that he did OTHER(SPECIFY) Elnot build or Improve for purpose of sale.).
❑l,as owner of the property,am exclusively contracting with licensetlcontractors toconstruct
the project(Sec.7044,Business and Professions Cotle:The Contractor's License Law tloes not PROVIDE LC.B.O.REPORT N0. V _
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the fallowing declaration:
❑I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, BUlldi g
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit Is Issued. Seismic
have an III maintain Workers Compensation Insurance,as required by Section 3700 of
the Labor C ,for the pe mance of the for whit this permit Is laeuetl.My Workers Total
Complim n Insure e c ler antl PoIfcy mbar a e: A/
Carrier �� Policy No �()�Q�J PERMIT THORIZATION DATE
CERTIFICATE OF EXE T ON FROM WORKERS'
COMPENSAT N INSURANCE N.C.O
(This section need not be completed If itis parmlt no hundV dollar! ($100)or leas.)
I certify that in the performance of the work for Ich t per it Is Issued I shall not employ
any persons any mann so as to become.. pt to I war rs'comPonaatlon Lawa of ca11- All roofs shag be inspected prior to ant roofing material being
fornla. installed. If a roof is installed without first obtaining an
Date / -4-�1poicant inspection,I agree to remove all new materials for inspection.
NOTICE O APP (CANT: If,eller making ti Car' of xemptlon,you should become licant understands a d will c I with all non point
subject to a Work m'Compensation provisions o bor Cotle,you must forthwith comply p Y
with such provisions or this permit shell t tleem oked. (7)
I certify that I have read this application antl s1.s a that the above Information Is correct.I agree
to comply with ell city antl county ordinances antl slate lawsretating to building construction,antl f V Ings O e I S° "Or *D _�r hereby authorize representatives of this city to enter upon the above-montlomid property for In-
spection purposes,
(We)agree to save,indemnity end keep harmless the City of Cupertino against liabilities,
judgments,coats antl expenses which may In any way accrue against eaitl Cityin F ICANT
Cry-
-of the ants,c g of thisand 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY