R 4883 (2) PERMIT 4883
APPLICATION FOR CITY OF CUPERTINO NUMBER R"
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
// 0 V .4& N ��� e..�— RESIDENTIAL - COMMERCIAL OTHER
OWNER'S If HAZARDOUS FIRE AREA
NAME �oti��� YES ❑ If yea–I understand 00 a Class A
roof assemblyredis requi .
� D /Wl ` No ❑ Waal Lc.B.o.a
ADDRESS 1/ /�f1(4'�/_ie7rJ��—C EXISTING ROOF COVERING
PHONE zS ��> NUMBER OF EXISTING COVERINGS
CONTRACTOR'S 'fi^%? �--.
NAME TO BE REMOVED TO BE RETAINED
ADDRESS ��, s TYPE OF ROOF COVERING
CITY&ZIP (o / ��� `-- EXISTING
PHONE L / / BUILT-UP ROOF ❑
CENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am Ilcenaed under provisions of Chapter B(commencing with Section• WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license le In full force and
effect' C_� Z WOOD SHINGLES
License Class Lic.Number
Date 7� Contractor S OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from the Contractor's Lice Law for the following reason.
(Sec.7031.5,Business and Professions Code: A of ry,of co which requires a permit to
construct,alter,improve,demolish,or rep airany str re,priW erluance,also requiresthe BUILT-UP ROOF Elapplicant for such permit to file a signed etefemant ih le li s ursuant to the provisions
of the Contractor's License Law(Chapter g(comr" of I ct 0)of Division 3 of the
• Business and Professions Code)or that ha40 of e f in asis for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7 15 by any gp Ica tl - mit subjects the applicant to
a civil penalty of not more than fIv ntlred donara
❑I,as owner of the property,; my ldlploye WOOD SHAKES wl a e as their sole compensation,will do ❑
the work,and the structure Is in land r o e sale(Sec.7044,Business and Profes.
signs Code:The Comrattoba LIce w e of ply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who dog iuq elk It, r through his own employees,provided that ❑
such Improvements are not Intends ed sale.If,however,the building or Improvement
Is sold within one year of compleflo , a ullder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or improve for purpose of sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Cotle:The Contractor's License Law close 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(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR. INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 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 following declaration:
❑I have and will maintain a Certificate of Consent to sell-Insure for Workees Compensation, 66 Building
Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this v
permit is Issued.
-11 have and will maintain Workers Compensation Insurance,as required by Section 3700 of Seismic
the Labor Code.for the performance of the work for which this permit is Issued.My Worker's 1/
Compenaabon eurance ca ler and Policy n�um�ber e: q� / • Total
Carrier -`(�C 11cyNo./c�/�� 8 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION the ON INSURANCE NO.100)o
(This section need not be completed If the permit is for one hundred dollars($100)or IasaJ y
1 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 Wort re' pensafio ws of Call. All roofs shall be inspected prior to any roofing material being
tornia. installed. If a roof is installed without first obtaining an
D��� — -- l yrs_ r i.�_iv inspection,l agree to remove all new materials for inspection.
NOrICE TO APPLICANT: It cher making t Cerllficale of Exemption,you ahoultl 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 ahalGbe deemed revoked. Source regulations.
I certify that I have read this application and state that the be.Information Is correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof Overings tob Class3;5 or better.
hereby authorize representatives of this city to enter upon the above-mentioned property lar in.
apache)purposes.
(We)agree to save,Indemnify and keep harmless the Clry of Cupertino against Ilabllltlse,
judgments,costs and expenses which may in any way accrue against Bald City...consequence SIGNATURE OF APPLICANT DATE
of the granting of this 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