R 4635 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 4 6 3 5
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-.3228 PERMIT EXPIRES IF WORK IS NOT STARTED
•
WITHIN DAYS OF PERMIT ISSUANCE OR
WI DAYSS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
t.
/L RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
'' 17'' YES ❑ 11 yes—I understand that a Class A
s'
NAME y +_ roof assembly is required.
NO ❑ Initial LC.B.O.If
it ADDRESS ` Q l In l.l.-� l q Pit iJ EXISTING ROOF COVERING
22
PHONE �� � 7 J / NUMBER OF EXISTING COVERINGS
CONTRACTOR'S 1} -
NAME ,-,t a I"I L-1 f9�;I .S ?O. � a TO BE REMOVED(L TO BE RETAINED'
CITY ADDRESS ZIP `_ •U TYPE OF ROOF COVERING
5-5�— 7 � � 7 EXISTING
PHONE ,BUILT-UP ROOF ❑
LICENSE 7
NUMBER `l S 3 - ASPHALT SHINGLES
(4
LICENS d underCONTRACTORS DECLARATION
hereby affirm that em Ilcansetl under Professions
of Chapter 9(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Cotle,end my license le In full force entl
effect.
WOOD SHINGLES ❑
License Cleas t� Lin.Numb r
Data 9 �T 6 contrp OTHER(SPECIFY)
OWNER-BUIL ER CECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason. EP q N I99n^�
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to SEP
construct,alter,Improve,demolish,or repair any structure,prior to Its issuance,also requires the BUILT-UP ROOF Elapplicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the 1,L1" �i 1 dt4
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).):
E]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 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
improves thereon,and who does such work himself or through his own employees,provided that ❑
such Improvements are not Intended or offered for sale.If,however,the building or improvement
Is cold within one year of completion,the owner-butlder 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(Sec.7044,Business and Professions Cade: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 Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
Ifirm untler penalty of perjury one of the following declaration: /
eve and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, Ulding
providetl for by Section 370D of the Labor Code,for the performance of the work for which this
permit lie lesuetl. Seismic
I�neve and will maintain Workers Compensation Insurance,as required by Section 3700 "'/')
,the Lobar Code,for the performance of the work for which this permit is issued.My Worker's
CompensationInsurance errier an Policy number are: 9 p' Total
Carrier Policy No. 62 1? a 3 PERMIT AUTHORIZATION DATE
CERTIFICATE OF XEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed if the permit is for one hundred dollars($100)or leas.)
1 certify that In the performance of the work for which this permit is Issued,1 shall not employ
any person in any manner so as to become subject to the Workers'Compensation Laws of Cali- All roo R s all be inspected prior to any roofing 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.
'`.•�y+ NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pp P y point
with such provisions or this permit shalgbe doomed 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 f coverings to C" r better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
sp(We) purposes.
(c agree to gave, Indemnify and keep harmless the City of Cupertino against liabilities. I
. judgments,coats and expenses which may in any we,accrue against sold City in consequence
of the granting of this permit. (� c;l MATURE OF APPLICAN 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
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