R 4975 (2) PERMIT R_ 4 9 71J
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
'
WITHIN DAYS PERMIT ISSUANCE OR
WI DAYSS FROM LASS T CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNERS
HAZARDOUS FIRE AREA
NiAM x1 Y\ V\ . Q Q YES ❑ If yea s I assembly
is req that a Class A
!`/ J root —I understand
de is required.
NO ❑ Intlal I.C.B.O.a
ADDRESS M Q / EXISTING ROOF COVERING
r PHO r + NUMBER OF EXISTING COVERINGS
CONTRACTfj,[i'S
NAME l/..Q TO BE REMOVED TO BE RETAINED
ADDRESS _ ✓/ A,IJw, TYPE OF ROOF COVERING
CITY&ZIP-II 20-in I(,�(j64�'-r
p}��` EXISTING
PHONE ^ EL L lq^+) BUILT-UP ROOF4U0 z 1:1
NUMBER ASPHALT SHINGLES 199fo
LICENSED CONTRACTORS DECLARATION - _
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ......l Vim•
7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and �J^`
effect WOOD SHINGLES ❑
License Cla e` Lac.Number
Date Conlrecior.
OTHER(SPECIFY)
R-BUILDER DEC RATION PROPOSED
hereby a InnBu that a exempt from the Contractor's License Law is the lollowing eras
(Sec.7031.5,Business and Profedemolish,
or rep Code: Any city or county which requ res also e permit to
construct,alter,Improve,t ofile a signed
or repeat any structure,prior to Its Issuance,also requires the BUILT-UP ROOF
applicant for such permit a flow a signed (comstatement that he It licensedSection
pursuant to the provisions
the
' of the ss and tPro License Law(Chapter a(commencerp with Section 7000)of for the ale the
Business and Professors Code)or that he is exempt ihrsra and the bees for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a cavil penalty of not more than five hundred dollars($500).):
E]1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sate(Sec.7044,Business and Profes.
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES
Improve$thereon,and who does such work himself or through hos own employees,provided that ❑
such Improvements are not Intended or offered for sale.II,however,the building or Improvement
is sold within one year of completion,the owner-Wilder will have the burden of proving that he dad OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,em excousovely contracting with licensed contractors to construct
the project(Sec.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 contracts for such projects
with a contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B&P.C.for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby and under tains of perjury one of the following declaration:
(or Wo
' ❑ have and will maintain a of the
Lab of Consent to parlours for Worker's Compensation, q Build1
as mit Is is kr by Section 3700 of the Labor Code,for the performance of the work for whim this ^ ,,I
ll
permit le ave and ,L/1��1"/� r`-I///yAW_ Seismic
❑ have and will the pert Worker's Compensation thef kfor Insurance,as required by d.My
Worker's
the labor Code,for the performance of thaw k for which this perms Is leauetl.My Worker's
'Ccm to Incur cesetae dPolicynu berate: Ig— �� Total
Cerra FPolicy ROM
APEPMITTHORIZATI DATE
CERTIFICATE OF E%E TION PROM WORKERS'COMPENSAMONINSURANCE N.C.0
(Thos section need not be completed ifthe permit la for one hundred dollars($100)orI certify that In the performance of the work for which this permit is issued,1 shall notoyany person In any manner so as to become subject to the Workers'Comp $tion Laws of call- Alinspected prier to any roofing material being
I ��l ��% I If � nst$led. If a roof is installed without first obtaining an
Date _'_,2= �Np`yl .nl I /�/� inspection,I agree to remove all new materials for inspection.
NOT subject tithe Worrkers'CompoTO APPLICANT: f,after nsatoon provisi ns of theflcate of Laborr Code,you mustufo fortd become
hwith comply Applicant understands and will comply with all non point
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 comply with all city and county,ordinances and state laws relating to building construction,and All roof coverings to be c SE;"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In- �� e
spection purposes.
(We)agree to save, Indemnify and keep harmless the City of Cupertino against liabilities,
ludgments,costs and expenses which may In eny way accrue against$antl City In consequence
ofthegreeting ofthis permit.
SIGNATURE OF APPLICANT D
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