R-4702 (2) PERMIT4702 ,
APPLICATION FOR CITY OF CUPERTINO NUMBER R�
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
• 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS A��•$�'�/� '\\�
RESIDENTIAL - COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
A -� YES ❑ If yes-I understand that a Class A
NAME "-'L't root assembly is required.
NO Initial I.C.B.O.#
ADDRESS
�`Q, I (��'x'-�.P� �p EXISTING ROOF COVERING
PHONE
C�� _ ( NUMBER OF EXISTING COVERINGS
CONTRA
1y T
NAME ( ��a�` TO BE REMOVED TO BE RETAINED
I`�-1 LNl]'
ADDRESS _ r• Mee J� TYPE OF ROOF COVERING
CITY&ZIP •7
iJ A EXISTING
.PHONE ��� L• 'I �� BUILT-UP ROOFCIC
❑
LICENS
NUMBER ' ASPHALT SHINGLES 13LICENSED CONTRACTORS DECLARATION
1 hereby affirm that l am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect. WOOD SHINGLES
License Cl as Lie.Number I El
I I Z3 QS Contraclor OTHER(SPECIFY) El
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec.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 its issuance,elan 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 Law(Chapter 9(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 ASPHALT SHINGLES Elexemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500).):
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 Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑Improves thereon,thereon,antl who does such work himaelf or through his own employees,provided that /1
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) ❑ AW
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's 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 Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
E]I am exempt under Sec. ,B 8 P.C.for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following tledwation:
❑1 have and will maintain a Certificate of Consent to self-insure for Workers Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this _
permit is issued. / Seismic
have and will the performance
Worker's Compensation Insurance,as required by Section 3700 of -
the Labor Code,for the pedarmanae of the work for which this permit is Iasuatl.My Worker's Total
Comp s on.In�sq�u�ranc ntlPolicynumberere: /A �( /y 1
Carr r *-'rr �'*'• � "PolicyNo.'•���TL*!7`, • 1J1ENMrrAu1H0FFIzATiON DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.Q VII Y Ur' L,'.�Cr11114U
(This section need not be completed If the permit Is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which is per it i ued,I shall not employ snt
any person in any manner so as to become subject m ih workers'cam enaetlan Lewy al Cali- All roofs shall be inspected prior to any roofing material being
forte. // A installed. If a roof is installed without first obtaining an
Date �� ApPilcant inspection,I agree to remove all new materials for inspection. I
NOTICET APPLI NT: I,after making this Certificate of Exemption,you sho coma
subject to the Workers'Compensation provisions of the Labor Code,you must forth h comply Applicant understands and WIII comply p y with all non point
with such provisions or this permit Shall be deemed revoked. Source regulations -
I certify that I have read this application and state that the above Information Is correctI agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof verings tobe lass"C"or better.
hereby authorize representatives of this city to enter upon the above mentioned property for In-
spection purposes. � S
(We)agree to save,indemnify and keep harmless way cc City ai Cupertino against liabilities, C c+J J
•
judgments,gran costs and expenses which may In any way accrue against said City In consequence
of me graining of this permit SIGNATURE OAPPLICANT 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
OFFICE COPY