R-4547 (2) PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 4547
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
OlD. Q(_Q.25 swr 11 IS'� RESIDENTIAL COMMERCIAL—OTHER
OWNER'S (n� 1 /n�• HAZARDOUS FIRE AREA
NAME I l'� W 1mod YES ❑ IIyes s Iunderstandthat. Class
roof assembly(sand that
�' `�� NO ❑ InNal I.C.B.O.p
ADDRESSr�L4�4� �Q►r�� _ Dn�� EXISTING ROOF COVERING
PHONE — v NUMBER OF EXISTING COVERINGS
CONTRACTOR'S nry
TO BE REMOVED TO BE RETAINED
NAME C 111��7 YJ
ADDRESS - ' TYPE OF ROOF COVERING
CITY&ZIP 0 &Ly1 .
L [�LJ��, EXISTING
PHONE�S� �r� 1 BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES ❑ -
LICENSED CONTRACTORS DECLARATION _n
I hereby affirm that I em Business
licensed under Professions
of Chapter 9(commencing In with Section WOOD SHAKES
7000)of Division 3 of the Business ono Professions Code,end mycoolicense Is In lull force and
5WOOD SHINGLES
Licence Class Lt..Number (35I °
Data Contractor
OTHER (SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED C �
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
construct,alter,Improve,demolish,or repair any structure,prior to Its issuance,also requires the BUILT-UP ROOF El7�
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Lew(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).):
I]I,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 sale(Sec.7044,Business and Profes-
sionsCode:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES El
thereon,and who does such work himself or through his own employees,provided that
such Improvements are not intended or offered 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(Sac.7044,Business and Professions Code:The Contractors License Law does not PROVIDE LC.B.O.REPORT NO.
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
F r. M
owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: All
7 �x
1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, •L 6 1996 BDI
•
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this !,
permit is issued. nil Y Ur
W have and will maintain Workers Compensation Insurance,as required by Section 3700 of LUr C 7 Seismic
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's
Compensation Ins lance mer entl Policy num r era: .��1I tt//���� '' � Total
Carrier 9 Policy No.ICSu.Ll1L� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C. O
(This section need not be completed It the permit Is for one hundred dollars($100)or less.)
I certify that In the performance of the work for which this permit Is Issued,I shell not employ
any person in any manner so as to become subject to the Workers'Compensation Laws of car- All roofs shall be inspected prior to any rooting material being
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: It.after making this Certificate of Exemption,you should become Applicant understands and will I with all non dint
subject to the Workers'CompensatlOn provisions of the Labor Code,YOU must forthwith comply . pP comply y p
with such provisions or this permit shat@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 all city and county ordinances and state laws relating to building construction,and All roof cover's t CI •C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes. /
(We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities, 6
jutl9mema,costs and expanses which may in any wey accrue a9alnst said Clty In consequence
of the granting of this permit. _GNAT O APPLICANT T
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