R 4849 (2) APPLICATION FOR CITY of cuPERTINo
NUMBIERR- -4849
INSPECTION DIVISION • PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
• WITHIN X)DAYS PERMIT ISSUANCE OR
160 DAYSSFROM LAST CALLED INSPECTION.
BUILDING ADDRESS
1h_P14 bw
RESIDENTIAL COMMERCIAL OTHER
OWNER HAZARDOUS FIRE AREA
YES ❑ If yes-I understand that a Class A
NAME aflroof assembly is required.
^ NO Initial I.C.B.O.of
ADDRESS 3 ��J�• ,L1 EXISTING ROOF COVERING'
PHONE J — - NUMBER OF EXISTING COVERINGS
CONTRACTO '�
_" TO BE REMOVED TO BE RETAINED
NAME
AOORESS r �I���/AA �. TYPE OF ROOF COVERING
CITY&ZIP /ac �Ids A '/ y� r -L/ ��
EXISTING
PHONE J (� BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION '
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 0l the Business and Professions Code,and my license Is In full force andeffe
700 ). `
WOOD SHINGLES G ❑
License Class
Da � Lic.Number
-b- Contractor-Egil OTHER(SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED
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 ❑
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 clvll penalty of not more than five hundred dollars($500).):
[:] WOOD SHAKES ��nu
1,as owner of the properly.or my employees with wages as their sole compensation,will tlo MAY' 9 1996.
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Proles-
pn
alone Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does ouch work himself or through his own employees,provided that r,i ❑
such Improvements are not Intended or offered for sale.If,however,the building or Improvement f ,
to sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑ V
not build or Improve for purpose of sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(See.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contract.for such projects
with a contmctar(s)licensed pursuant to the Contractor's License law. PROVIDE MFGR,INSTALLATION SPECS.
❑1 am exempt under Sec. ,S&P.C.for this reason
Owner Dere
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will mainteln a Certificate of Consent to self-insure for Workers Compensation, Building 167
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit Is Issued. Seismic
❑1 have and will maintain Workers Compensation Insurance,as required by Section 3700 of 1/
the Labor Code.for the performance of the work for which this permit Is issued.My Worker's l 6pc� Total
Compen IInnte-ur{�-npca terrier and Policy
n=bberr are;
Carrier /"'/ v--�L�✓iC 1..1/!1 Policy No, , PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WO KERS'
COMPENSATION INSURANCE N.C.0
(This section need not be completed If the permit Is for one hundred dollars($100)or lee..)
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 Cell- All roofs shall be inspected prior to any roofing ma erial being
fornia. installed. If a roof is installed without first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
subject to the WICE TO orkout'Compen,after sation tion provisions Ofthelcate of Labor Code,you mustuforthwith loecome
comply Applicant understands and will comply with all non point
with such provisions or this permit shalgbe deemed revoked. source egulations.
I certify that 1 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 Ill coverings •be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection(We) purposes. \
(We)agree s save,penesIndemnify and keep harmless the City ai Cupertino against liabilities, 1. r
judgments,costs and expenses which may In any way accrue against said CIN In consequence
Olins gmming time permit. SIGNATURE OF APPLICANT DAT
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