R 4721 (2) APPLICATION FOR CITY OF CUPERTINO
nPE BE R- 4721
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
• . WITHIN DAYS PERMIT ISSUANCE OR
100 DANSS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL - COMMERCIAL OTHER
OWNER'S , nK1 C' HAZARDOUS FIRE AREA
NAME `�` �'�J �1''"C(�(, _r— VES ❑ If yt assembly stequired. ssA
ADDRESS- If I VIS��-0�� iv� NO Initial LC.B.O.#
� 11 u CJ� 'EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S '
NAME ���('„ TO BE REMOVED TO BE RETAINED
ADDRESSg4 O S ,5 /) ., F COVERING
CITV 8 ZIP �4U
.�
EXISTING
PHONE— 2 C1 Q S t A BUILT-UP RO ❑
LICENSE
NUMBERiEs l ASPHALT SH LE
LICEN D CONTRACTORS DEC RATION
I hereby affirm that I am licensed under provislons of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and
effect,
WOOD SHINGLE
Licence Class Lis.Number
Date -BUIUDE
ontractor OTHER(SPECIFY) ���(GG/// ❑
OW from th ILDER DECLARATION PROPOSED
hereby affirm that am exempt from the e: Any
License Lew for the following permit
t.
(Sec.70315,Business and Professions Code: Any city or county which requires a permit to
construct,alter.improve,demoto file signed air any statement
he prior loits issuance,to
requires the BUILT-UP ROOF ❑
applicant for such permit to Ills a signed Chapter 9(co m that g itlicensed p 000)oto the provisf the
' of the ss an Pro License Lew Sorthat h(commencing with Section 7000)of Division 3 of the
exemption.end Professions f Cotla)or that he a exempt therefrom and the bele for the alleged ASPHALT SHINGLES ❑
exemption.Anyf violation more
of Section hundred
by any applicant for a permit subjects the applicant to
a civil penalty of not more then live hundretl dollera($500).):
[ 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(Sac.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 r
such Improvements are not Intended or offered for sale.If,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) 1:1 �
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does 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 contractors)licensed pursuant to the Contractors License Law, PROVIdE MFGR.INSTALLATION SPECS.
[II am exempt under Sec. ,B 8 P.C.for this reason
Owner thole APPLICATION DATE VALUATION PERMIT F E
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, P4
B 7Buitdies provided for by Section 3700 of the Labor Cotle,for the performance of the work for which this "1 ®permit is Issued, i'_ C
❑ have and will the performance
rmacWorker's f the work
for Insurance,as required by Section 3700 s $.+`�
,the Labor Code,for the performance of the work lar which this permit Is leauetl.My Worker's y q$: Q ( � Total
Companeatl urance terrier nd Policy nu er ra'�LyT�_ v
Carrier /olicyNo. (7PE MIT THORIZATION DATE
CERTIFICATE 011i EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.I] yy nx�r�' "w/� �j
(This taction need not the completed If the permit Is for one hundred dollars($100)or leas.) vyC�JyI yL
I certify that In the performance of the work for which this permit Is issued,I shell nal employ
any person In any manner as as to become subject to the Workers'Compensation Laws of Cali- All roof^shall be inspected prior to any roofing material being
fornie. installed. If a roof is installed without first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
subject to theICE OWoP era'Compel,after nsation provsionls ofetheicate Labor`Code,you mustufo forthwithbecome
Applicant understands and will comply with all non point
with such provisions or this permit shalQbe deemed revoked. y comply
source regulations.
I certify that I have read this ePPllcellon and state that the above Inbrmatlon Is correct.I agree
to comply with all city and county ordinances and stale laws relating to building construction,and All roof cov In lobe�Ss"LC" better.
hereby authorize representatives of this city to enter upon the above-mentioned properly for In-
spection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
• lutl menta costa and expenses which may In any way accrue against 9eltl City... AT
consequence
of t�a gr9ngrug of this permit. SIG UR OFAPPLICANT
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