R 4903 PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 4903
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777.3228 PERMIT EXPIRES IF WORK IS NOT STARTED
'
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
WI
DAYS FROM LAST CALLED INSPECTION.
BUILDING
P/ADDRESS
��( /I
/ W RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ,
yes—I understand that a Class A
NAME root assembly is required.
NO ❑ Initial I.C.B.O.11
ADDRESS EXISTING ROOF COVERING
PHONE S'S�,S 3aIf %
NUMBER OF EXISTING COVERINGS S lie +
CONTRAC R'S
413 11
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS �-- TYPE OF ROOF COVERING
CITY a ZIP--35 Y IYlta /�yl-rt Beta 2 5 r� .
r �' ) EXISTING
PHONE Q" BUILT-UP ROOF El
LICENSE
NUMBER ASPHALTSHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter S(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full fame and
enact. WOOD�� WOOD SHINGLES ElLicense Clea Lk.Number
S�Z6—� OTHER(SPECIFY) ❑
Date _Contractor
OWNER-BUILDER DECLARATION PROPOSED
hereby affirm that I am exempt from the Contractor's License Law for the following reason.
IS
7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,alter,Improve,demolish,or repair any structure,prior to lin Issuance,also requires the BUILT-UP ROOF El
for such permit to file a signed statement that he Is licensed p uant to the provisions
' of the Contractors License Law(Chapter 0 bommencana with Section f Division 3 of the
Business and Professions Code)or that he Is exempt iherotromapd.t asli for the alleged
ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any appllcentpr.6p rMll eu aapplicant to
e civil penalty of not more than five hundred dollars($500)1: El
theas owner of the property,or my employees w thtvagas as thin pensation,will do WOOD SHAKES
the work,and the structure Is not Intended or Offa r said s . 4 usiness and Profes-
aloneCode:The Contractors License Law doss' la yto at property who builds or WOOD SHINGLES
Improves thereon,and who dose such work4nin Orth u employees,provided that El
such Improvements are not intended or OflGrad br I o sv6r,the building or improvement
Is sold within one year of complellan,the bx�t sr-W w ve the burden of proving that he did OTHER(SPECIFY) El).
not build or Improve for purpose of sale.
❑I,as owner of the property,am exclusively or,14cing with licensed contractors to construct
the project(Sec.7044,Business and Profeaftris Code:The Contractors License taw 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(a)licensed pursuant to the Contractors Licence Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B 8 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 fallowing declaration: �f
E]I have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, Belding'o
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this S.
permit Is Issued ��� / �{/ s✓� Seismic q117
have end will the Performance
Worker's Compensation Insurance,as required by Section 3700 0/ '
ihyLabor Cade,1 the performance of the work for which this permit Is Issued.My Workers 21 1996 Total
Cddmpensatlan ante terrier d Palley number ere:
Darner G N&Je 3�/ZZ/�a r
PollyNo. PERMIT AUTHORIZATI N DAT
CERT#PICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE N.C.p
(This section need not be completed If the permit Is for one hundred dollars($100)or less.) xPic
I certify that In the performance of the work for which this permit Is Issued shell not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Cell- roof.^•shall be inspect d prior to any roofing material bei
farnia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOT subject I.the a WorkereTO s'Compef,after nsation provisionis of theicate of Labor Code,you must forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shall,,be doomed revoked Source regulations.
I certify that I have read this application and elate that the above Information Is correct.I agree
to hereby ty wlthallze rep and county ordinances and eupon the
tobuildingantiedproperend All ro��coverinpS to be class°Ci°Or better.
hereby authorize city and county of than city to d state
enter upon the sing to entlon construction,property for and
11 roo � CC/////in
spection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against Ilabilltlea, e
' ofdthe gre cling of this perrmiL monle,costs and ae which may In any way accrue agalnnt Bald City an consequence SIGNAT RE OF APPLICANT 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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