R 4752 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBERR_ 47527
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN/90 DAYS OF PERMIT ISSUANCE OR
• 1co DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
1 RESIDENTIA COMMERCIAL OTHER
OWNER' / (/+/� �.,I HAZARDOUS FIRE AR A
`I—�-�k'� \ 1 1-�_ (..�/�f ��� YES ❑ ttyess Iunderstandthat. Class
NAME roof assembly is required.
NO Initial I.C.B.O.N
ADDRESS EXISTING ROOF COVERING
PHONEq NUMBER OF EXISTING COVERINGS
CONTRACT > )
TO
NAME n BE REMOVED TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP 'n\
✓ EXISTING
PHONE BUILT-UP ROOF ❑
CENSE
NUMBER ASPHALT SHINGLES ❑
—LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter B(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Cotle,and my license Is in full force and
enact. WOOD SHINGLES ❑
License CI e U. Number
Date conimmorL,8 A 1, AID LOTHER(SPECIFY) ❑
ER-BUILDERD W N PROPOSED
hereby Iflrm that em exempt from the Con Gfare License Law for the following reason.
(Sec.7031. Business and Professions Code: blty or county which requires a permit to
construct,alter,Improve,demolish,or repel any.et ct a, dor to its lasuance.also requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed state�ent 1 t ape licensed pursuant to the provisions
•
at the Contractor'.License Law(Chapter g(common Ith Section 7000)of Division 3 of the
Business and Professions Code)or that I amp are am and the basis for the alleged ASPHALT SHINGLES 'Yid
exemption.Any violation of Section 703145 by a II r a permit subjects the applicant to
a civil penalty of not more than five hundred III
❑I,asowneroftheproperty,ar4em a as heir sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is notdhtsnd 'or 1 retl(c sale(Sec.7044,Business and Profes. A
alone Coda:The Contractor's,Llb L stet %to an owner of property who builds or WOOD SHINGLES �� 12 yy '
Improvesthereon,andwhodoe uc11� ImseJ1'or through his own employees,provided that p
such Improvements are not IInt tlad a lar sate.If,however,the building or Improvement O
Is sold within one year of codlpie he own /bulltler will have the burden of proving that he did OTHER SPECIFY
not build or Improve loror Improve purpaaeeeeee 0.).� (SPECIFY) ❑
❑I,as owner of the property,A($excJuelvely contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor($)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
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Cadlllcate of Consent to aslMnsure for Workers Compensation, Buildin
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this g
permit Is Issued, Seismic
❑ neve and wool the performance
Workers f thq%w rk for Insurance,as required by Section 3]00' 32 7
the Labor e,kr the pedormenca of lh rk for which this permit is leeued.My Worker J
Comp n aur and Policy mbar are: —rrI r r y '9 Total
Caryl Policy o. \ -"' PERMIT AUTHORIZATION PATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE KC-0
(This section need not be completed If the permit Is for one hundred dollars($100)or leas.)
I certify that In the performance of the work for which this permit le Issued Ishell not employ
any person In ant manner so as to become e M e Workers' ompenaa Ion Laws of Cell- All roots S I be inspected prior to any roofing material being
forme' installed. If a roof is installed without first obtaining an
Data am e ll�o\ inspection,I agree to remove all new materials for inspection.
NOTICE TO A P (CAN : II,an making this Certificate of Exemption,you should become
subject to the Workers'Co ensatlon provisions of the Labor Coda,you must forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked, source regulations.
I certify that I have reed this application and state that the above Information Is correct.I agree
to comply with all city and county ordinances and eters lewa relating mbuilding construction,and All roof S7�WfJ 4AA
toS"C"or betterhereby authorize representatives of this city to enter upon the above-mentioned property for In-spection purposes.
(We)agree to save,Indemnify and keep harmle$e the City of Cupertino against liabilities,judpmenta,costa antl expenses which may In any way accrue against ultl Cly In coneoquencaonhegranungolwepsrmu. SIGNATU EOFT DAT'
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
L/ OFFICE COPY