R 4747 (2) PERMIT
APPLICATION FOR CITY of CUPERTINO NUMBER R- 4747
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
.�
WITHIN DAMS PERMIT ISSUANCE OR
WIT DAVES FROM LAST CALLED INSPECTION.
BUILDING ADDRESS �� //� IJI} � /� /}/.
O2 O�i 10201 Y �/ I' V\ RESIDENTIAL��!_COMMERCIAL OTHER
OWNE HAZARDOUS FIRE AREA
r
VES [3 It yes—I understand that a Class A
NAME roof assembly is required.
�-g �Y1 1I� NO ❑ Ininal I.C.B.O.a
ADDRESS- d�3 //b 1 EXISTING ROOF COVERING
PHONE ! 2s 8, q— NUMBER OF EXISTING COVERINGS
CONTRA R'S
NAME TO BE REMOVED TO BE RETAINED
r ADDRESS TYPE OF ROOF COVERING
CITY a ZIP EXIST.
I TI G
f, PHONE BUILT-UP ROOF
LICENSE
NUMBER ASPHA SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WO KES ^ ❑
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
enact, WOOD SHI ❑
License Cle9!-� Lia Number OTHER(S 1996 ❑
Dote Contractor
Y p NER the Conn DECL License
g PROPOSED pl*p r I IIVU
-41
hand affirm that a exempt from the Contractor's License Lew for the fins a eras to v
(Sea 70315,Business and demolish,
or rep Code: Any city or county which requires a permit to
construct,eller,improve,demolish,or repeat any structure,prior to its issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to floe aChapt statement nci he Is licensed pursuant to the provisionsothe
oI me Contractors License Lew(Chapter h(commencing with Section 7000)of Division 3 of the
ex
Business ptio antl violation
Code)or that he Is exempt therefrom and the su basis forhe the alleged ntto ASPHALT SHINGLES
exemption.Any f o t more
of Section 7031.5 by any applicant for a permit subjects the applicant to Ilk
ecivil penalty of notmorsthan five hundred
my
(h wag): WOOD SHAKES
[]I.as owner of map re is n tI to employeeswith wages as melt sole compensation,will do ❑
the work,and the structure is not Intended ores not for sale(Sea o an owner
of Ropiness and builds
o-
Improvns Improves
The Con whodoessuchLaw workhi doesnot applyghhisownefployerty es,pro provided
at WOOD SHINGLES ❑
Improves thereon,and not does work sedan or through his own employees,improvement etl that
such Improvements are not completion,
leb n,the
onemtl for pale.ill however,the hulloing a,Improvement
Is not
tbuild or
year of forpurposelofstheownerbulltlerwillhavetheburtlrnofprovingthatheoltl OTHER (SPECIFY)
❑
not build or Improve for purpose al 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 contractor(s)licensed pursuant to the Contractors License Law.
[I PROVIDE III INSTALLATION SPECS.
I am exempt under Sec. ,B&P.C.for this reason
Owner
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑ haveand willmeant37a of the
ate bof Consent to performance
c ofthkewo Compensation, I I �i BUlldl
as Provided for dyill Section maintain
a of the Labor Code,for thepednsure for
rWthework for which this
enation, I
permit Is issued. $elSrrllC
❑I have and will maintain Worker's Compensation Insurance,as required Section 3700 of
t the Labor Code,for the performance of In 0o
for which this permit Is le@@1ued.My 44 Wyy��prkkk (((e���
ppp
Comp a Insu nc ca r antl Policy n badere: 11�as- (17 Total
careerclt Policy
N CERTIFICATE OF EX&7TIO ,11 ) _`� PERMIT AUTHORIZATION DATE
CERTIFICATE OF E%E TION FROM WORKERS'
�I COMPENSATION INSURANCE N.C.O,
(This section need not be completed If the permit Is for one hundred dollars($100)or less.)
I ceNgy that In the performance of the work for which this permit Is Issued,I shall not am ploy
any person in any manner so as to become subject to the Workers'Compensation Laws of Cali. All roofs 5149 be inspected Prior to any too tng aerial e'
fornia. installed. If a roof is installed without first obtaini a
Dale Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,ever making this Certificate of Exemption,you should become Applicant understands and will comply with all non Olnr
subject to the Workers'Compenpabon provisions of the Labor Code,you must forthwith comply pP P y P
with such provisions or this permit shallibe deemed revoked. Source regulations.
I certify that I have read this application and state that the above Information is correct.I agree
to hereby uthoriwith ellcaryand tatIV9ounty ordinances toentetupon the g to
entii odor penton,on and All roof covert fO bC °Or bO""''-
hereby authorize repreaentatives of this city to anter upon the above-mentlanetl property for In- �)
sp(We) purposes. J
(We)agree to save,Indemnify and keep harmless the Clry of Cupertino against liabilities,
of the gra costa and expenses which may in any way accrue against said City In consequence
of the granting of this permit. SIGNATURE OF APPLICANT DA E
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 }