R 4611 (2) PERMIT R_ 4 611
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
�+a WI180 DANS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
r I RESIDENTIAL COMMERCIAL OTHER
OWNER HAZARDOUS FIRE AREA
NAME 7C1 fr� NES ❑ II yes-I understand that a Class A
roof assembly is required.
\ NO [IInitial I.C.B.O.q
42 /9 EXISTING.1910017-MVIERING
ADDRESS `` / r4 '�
PHONE Q rJ O NUMBER OF EXISTING COVERINGS
CONTRACTOF/yS�
NAME &_, I So,% lirltl Q \ TO BE REMOVED TO BE RETAINE��
ADDRESS - TYPE OF ROOF COVERING
CITY&ZIP ♦V
EXISTING
PHONE. BUILT-UP BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES ❑
1ICENSE5 NTRACTORS DECLARATION
I hereby allirm thu I em licensed under provisions of Chapter B(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code and my license is In lull force and
effect.
WOOD SHINGLES El
Cleanse Claes � �^� Lic.Number
wZ. OTHER(SPECIFY) ❑
Dere Contractor
11- 6WNER-Bt11LDERDECLARA ION PROPOSED
I hereby affirm that I em exempt from the Contractor's License Lew 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,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 Law(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 ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of not more than five hundred dollars($500).): QQD$HAKES
EJ 1,as owner of the property,or my employees with wages as their sole compensation,will do ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes.
tone Code:The Contractor's License Law does not apply to an owner of property who builds or D 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.). \
CD 1,as owner of the property,am exclusively contracting with licensed cent rectore 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 Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt untler Sec. ,B 8 P.C.for this reason
owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE1 VALUATION PERMIT FEE
P
I hereby affirm untler penalty of perjury one of the following declaration: r �
❑ have and will maintain 37 a of the Lab of Consent to self-Insure for of the
Compensation, )/ :ed BGildin��
as promit IsI tl for by Section 3]00 OI the Labor Code,/or the performance of the wrork for which this �� �O
permit leve and l]'-�/ � Seismic
❑I have and will maintain Workers Compensation Insurance,as required Is u Section 3700 a
the pens Cade,for the performance of the wror for which this permit is Issued.My Workeran/
-the
In liras mrrlar en Ilcy nu r ere: �L/ � (y Total
carrier Policy No.�s:>G c� R I AUTHORIZATION DATE
CERTIFICATE OF EX MPTION FROM WORKERS'
COMPENSA NINSURANCE N.D.0
(This section need not be completed if the permit Is for one hundred dollars($100)or less.)
1 certify that In the performance of the work for which this parmikis Issued,I shall not employ
any person In any manner so as to berme sub lgs the Worker ompensatlon Laws of Cell- All roofs shall be inspected prior to any roofing material being
ferule. \/ C ' installed. If a roof is installed without first obtaining an
Data ilIcant inspection,I agree to remove all new materials for inspection.
NOTICE subject to the Wo keres'CompePLIANT: fne torn provatine of themakIlcers Labor Code,you must fo thwlithcecome comply Applicant understands and will comply with all non point
with such provisions or this permit shelgbe deemed revoked. source regulations.
I certify that I have read this application and state that the above Information is correct.)agree
to comply with all city and county ordinances and state laws Totaling to building construction,antl All rocItroverings t0 a cl SS"C°Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In. f
speedo)purposes. �" - ♦ /j/Z�/�`
(We)agrees and
e,expenses
w and keep harmless the City ai Cupertino against Ilebllltloe,
ofjudgments,the gran cote end permit. s which may In any way accrue against seltl City In coneaquonce
of the granting of this permit. SIG E OFAiaPLIMNT 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 COPV