R-4748 PERMIT
APPLICATION FOR CITY of cuPERTINo
NUMIRERR- 4748
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT - (408)7T7-3228PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS -
Ll 3 "d
v RESIDENTIAL COMMERCIAL OTHER
OWNER'S _ R FIRE AREA
(3YES ❑ If yes–I understand that a Class A
. .NAME / t7 A/��Q 1 l V.h11 Q� got assembty is required.
NO Initlat I.C.B.O.If
ADDRE EXISTING ROOF COVERING
PHONE — NUMBER OF EXISTING COVERINGS
C CTOR'S
O TO BE REMOVED TO BE RETAINED
h NAM
6PE OF ROOF COVERING
EXISTING
BUILT-UP ROOF ❑
CENSE
NUMBER ASPHALT SHINGLES . ❑ -
LICENSED CONTRACTORS DECLARATON
I hereby affirm that I am Ilcensm under provolone of Chapter S(commeodng with Section WOOD SHAKES
7000)of DMelon 3 of the Business snq Profeeelons Code,entl my Iloense o In full force end
effect.
WOOD SHINGLES ❑
Llcsnhh,CIatLlo.Number
Dale con o OTHER(SPECIFY) p ❑^^
ER-B ER CLARATION PROPOSED
I hereby a Irm that a+n exempt from Me trsdore Dcerale Lew for the following reeeon. ��
(Ssc.7031.5,Buetheea end Proleasfons Any dry or cpunry which requires a permit t .N1 p
can,Vuct,ever,Improve,demolish,or repair an tructure,prior to Its Issuance,also requires the BUILT-UP ROOF Cl y 7�.
applicant for such permit to file a signs statems that he Is licensed pursuant to the provisions k�
of the Contredor'a License law SCnept r e(co Ung wlfh Section 701X1)of Division 3 0l the. OF
Business end Professional Code or he l t' shall and the bathe far the alleged ASPHALT SHINGLES f'Ur
sxamptlm.Airy vlootlan of Section 703 try rit for a permit subjects ties applicant to -C
e CMI perolry U not mors than avehiu lf (,36001.): yh
❑I,as owner of me pro pe ,or my p with"gas as their sole compensation,will co WOOD SHAKES ❑
the work,entl the strudur Mt I 000flerm for Bele(Sec.7044,Business entl Profen
sons Code:The Contra se Lar does not appy to an owner of property who builds« WOOD SHINGLES
Improves thereon,and d went,himself or through his own employees, resided that ❑
such Improvements ere res an d or offered for axle.It,however,the W Ming or Pmprovement
Is sold wllhln ona year of m gar,theownerbulltlerwlllhavetnewmenofprwingthethedld OTHER(SPECIFY) ❑
not build or Improve toi ur of ealeJ.
❑I,ss ownof of the prcperry,em exclusively contracting with Ilosirl contractors to construct
the pros (Sao 7ow1BineInns and Profeeakeal Code:The Contrtecmor'e Looas Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who bunds or Improves thereon,and who contracts for such prgeds
with a contnador(e)licensed pursuant to the Contractors Ucenee Law, PROVIDE MFGR. INSTALLATION SPECS.
❑1 em exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby of firm under penalty of perjury one of the following decleratlon:
❑1 have and will maintain a CenHkate of Consora to self4nsure for Workers Comperalatkm, Building
as pro�kled for by Section 3700 o1 the Labor Cada,for the performance of the work for which this
pennll Is lowed. IS) q�
/1/�-� SBISTTIIC 'A
❑I lalve and will malnieln Workers Compeneetlon Insurance,as required by Section 3700 0l w
the Leber Code,for the performance of a work for wh Nle permit o Issued,My Workers
Com n In u n e ce for end PoI number an�-iT't d 1���5- Total
Ca'ir•�– PcIcy No PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CL]
(This secdon need not be completed if the permit is for one hundred coffers($1 DD)or lees.)
I certlty that In the performance of the work for which this permit Is Issued,I shall not employ
any person In any manner te as to become subject to the Workers'Compernabon Laws of Cl All roofs Shall be Inspected prior to any roofing material being
forns. installed. If a roof is installed without first obtaining an
Date Applicem inspection,I agree to remove all new materials for inspection.
Nonce To APPLICANT:rs'Copo,tenor making
klrg this of the Lab r ode, oui m sOforl ld become Applicant understands and will comply with all non point
subject to BTI Workers'Com ,after king the of the Leber Code,
with such provlaons o this permit shell be deemed revoked. comply source regulations.
I certify that I have reed thio application and state that the above Information Is coned.I agree
to cernply with all city and county ordinances and state laws reloting to building conetrucdon,and All roof coven.ngslp be class"C"or better.
hereby authorize repreeenmu lNas of this clmy to enter upon the above-mentioned property for In-
spmfton purposes. I
(We)agree to save,indemnlfy and keep harmless the City of Cupertlrw against Ilebill ars,
of the gran croeo eM expenses whklr mak In any way accrue against veld Clry In conssquenco
of the enne,co is nle permit. SIGNATURE OF APPL C N ATE
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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY