R 4969 PERMIT R_ 4969
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
WI180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDREESSSS.. I
Q&A W y�,Q
RESIDENTIAL-2k—COMMERCIAL OTHER
OWNER'S // HAZARDOUS FIRE AREA
NAM xl G J Y,� r' ell- YES ❑ If yes I understand a Class A
2�J L7 h (n Yui K CG n roof assembly–lundo is required.
/'�.� NO ❑ Initial I.C.B.O.A
ADDRES�r 7 7 l�� "� `� ��_ EXISTING ROOF COVERING
PHONE '/'0 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS TYPE OF ROOF COV
CITY&ZIP
EXISTING
PHONE BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES NVI.
LICENSED CONTRACTORS DECLARATION
v p p g WOOD SHAKES �+
hares affirm that em si licensed under Professions
of Chapter 0(commencing in with Section
7000)of Division 3 0l the Business entl Prolesslons Code,end my II<enea 19 in lull force and
effect. WOOD SHINGLES JU�� 8
License Cleve Lia Number 1996
Date Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION LII I l ,- VUrCr I t AQ
I hereby affirm that I em exempt from the Contractor's License Lew for the following reason. PROPOSED
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
Cametructq aIter,Improve,demolish,or repair any structure,prior to Its issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Lew(Chapter S(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHAL SHINGLES
exemption.Anyviolation of Section 7031.5 by any applicant for a permit subjects the applicant to 4 fn+
a civil penalty of not more than live hundred dollars($500).): O v-
0
eTC t'.62r
❑I.as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not intended or offered for sale(Sec.7044,Business and Profes.
sions Code:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,provided that ❑
such Improvements are not Intended or offered for sale.If,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER (SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,em exclusively contracting with licensed contractors to Construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractors)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPEC$.
E]I em exempt under Sec. ,B S P.C.for this reason
Owner
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
S, I hereby affirm under penalty Of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit Is Issued.andU Seismic _/9Q
.s ❑1 have entl will maithe performance
rmancWorker's f the work
Insurance,as required Is
by Section 3700's -�
the Labor Code,for the performance of the work for which this permit le laeuetl.My Worker's
'Compensetlon Insurance carrier and Polley number are: Total
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need not be completed If the permit Is for one hundred dollars S1 00)or less.)
I certify that In the performance of the work for which this permit Is Issued,I shell not employ
any person In any manner so as to become subject to the WorkereCompensation Laws of Cali. All roofs shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE ou shoulecome
subject to the OWorkers'CompeAPPLICANT: Ina tion proviafter sionis of theft Labor Code,yoiu mustforthwiitthbcomply Applicant understands and will comply with all non point
with such provisions or this permit shaffbe 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 Il roof Covert 0 b Class"C°Or bettor!
hereby authorize representatives of this city to enter upon the above-mentioned property for In. fe
speedo)purposes. �
agree
(We)agree a save, eases lw and keep harmless w as Ice City of Cupertino against liabilities,
of t marts,cote and expenses which may In any war'accrue against said Clfy in canasquence
of 1Re granting of this permit.. )SIGNATURE 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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