R 4911 (2) APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 4 911
^ INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 190 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM UST CALLED INSPECTION.
BUILDING ADDRESS
`RESS RESIDENTIAL_! COMMERCIAL OTHER
owNER s HAZARDOUS FIRE AREA
VES ❑ H yes—I understand that a Class A
NAME 'd a assembly Is required. -
• oo -- NO Initial- I.C.B.O.#
ADDRESS EXISTING ROOF�C.O,VE/R�ING
PHONE
NUMBER OF EXISTING COVERINGS cl �'L -
CONTRACTOR'S /
Q TO BE REMOVED_�,�TO BE RETAINED
NAME_
ADDRESSTYPE OF ROOF COVERING
CITY&ZIP
(� EXISTING
PHONE d S-- 71.1 0 q Z BUILT-UP ROOFLICENSE
p�
NUMBER Z ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES El7000)of Division 3 of the Business and Professions Code,and my license le In lull force and
etre"` _ WOOD SHINGLES ❑
License Claes Uc.Number 35$2,
Date Contractor C 91
OTHER(SPECIFY) ❑
OWNER-BUILDER DE RATION pROPOSEf)
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec.7031.5.Business and Professions Code: Any city or county which requires a permit to
applicant alter, hPefi it to file demolish, n repair anystructure,prior tope issuance,puruant alsoreguiresovisi the BUILT-UP ROOF
applicant for suchpermit to Illsah,or restatementthat he Is licensed to Its pursuant the provisions
of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)Or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES ❑
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500).):
C3 1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for&ale(Sec.7044,Business and Profes.
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,provided that ❑
such improvements are net intended or offered for sale.ll,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,em exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Lew does net 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)Ilcenaetl pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,S&P.C.for this reason
Owner Data
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 sell-insure for Worker's Compensation, Building
pe mit is Is for by Section 3700 of the Labor Code,for the performance of the work for which this
permit lav and /�.�', 7vy.J,�^ Seismic
❑ have and will maintain Woancefthe Compensation Insurance,as required by Section 3700 of S
the Leber Code,for the pe o mance of the work for which this permit Is leeuetl.My Worker's
Comport eur ce ar r and Policy number are: Total r/*R!� !r
Carrier Policy No.,e�/ LPERMIT AUTHORIZATION DATE
CERTIFICAT OF EXEMPTION FROM WORKER
COM NSATION INSURANCE N.C.O
(This section need not be completed If the permit Ie for one huntlretl dollars($100)or lees.)
I certity 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 Call./'All rocifs shall be inspected prior t roofing material being
tennis. �(�/`�� installed. If a roof is installed without first obtaining an
Date / �/ /_ Applicant ( eA� inspection,I agree to remove all new materials for inspection.
NOTIc 1114 APMILICAANT. It,after making this Certificate of Exemption,you should became Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP P Y P
with such provisions or this permit shalfbe deemed revoked. SOUfCO regulations.
I cortify,that I have read this eppllcatlan and state that the above Information Is correct.I agree
to comply with all city and county ordinances and state Tawe relating to building construction,and All roof coverings to be class"C"Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spectionpurposes. i
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
judgments,
udgments,coats and expeneae which may In any way accrue against said Clty In consequence
Of the Qrenilnp of this parmll. SIGNATPJRE OF APPLICAXT '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