R 4987 (2)Ljf,�
6
OFFICE COPY
PERMIT R_
NUMBER 4987
APPLICATION FOR CITY OF CUPERTINO
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS /2
L,
RESIDENTIAL COMMERCIAL OTHER
ow S +
HAZARDOUS FIRE AREA
K/ES If yes — I understand that a Class A
roof assembly is required.
N ❑ Initial I.C.B.O. &
ADDRESS -
EXISTING ROOF COVERING
PHON
ER OF EXISTING COVERINGS
CONTR
NAME
BE REMOVED TO BE RETAINED
,l
ADDRESk_ �j
V
TYPE OF ROOF COVERING
CITY & ZIP l
EXISTING
/�
93 ���-
1�
PHONE
BUILT-UP ROOF ❑
LICENSE
NUMBER
ASPHALT SHINGLES ❑
CEN ED CONTRACTORS DECLARATION
I hereby affirm that I am licensed underprovisions of Chapter g (commencing with Section
WOOD SHAKES
7000) of Division 3 of the Business and Professions Code, and my license Ie In full force and
effem. (/ l U}/��
WOOD SHINGLES ❑
License Claes-� f LIc. Number 11y��
a�
OTHER (SPECIFY) ElO
Datecontrocror �
N-BUILDERDECOIRArION
I hereby of rm that I am exempt from the Contractor's License Law for the following reason.
PROPOSED
(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 licensed pursuant to the provisions
of the Contractor's License Law (Chapter 8 (commancln w Section 7000) of Division 3 of the
Business and Professions Code) or that he is axe t t to IIf`antl the basis for the alleged
exemption. Any violation of Section 7031.5 by licen
ASPHALT SHINGLES
any r plrmlt subjects the applicant to
a civil penalty of not more than live hundred coke 500).): )
the Ir
WOOD SHAKES ❑
❑I, as owner of property. or my employe... t a sole compensation, will do
the work, and the structure Is not Intended or offered f sl Be 7044, Business and Profes.
61ons Coda: The Contractors Lice ee.Lew ago, as no a ep owner of property who builds or
Improves thereon, and who do him
himglf his own emDloy9es,provltletl Nat
such Improvements arenot Inlen r offer. I r e. itwaver, the building or Improvement
WOOD SHINGLES ❑
Is sold within one year of complat n,t Iltl have the burden of proving that he did
not bulId or Improve for purpose of sal
OTHER (SPECIFY) ❑
❑l,asowneroflheproperty,am exclusv ratting with licensed contractors to construct
the project (Sec. 7044, Business and Professions Code: The Contractors License Law des 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 Contractors License Law.
PROVIDE MFGR. INSTALLATION SPECS.
❑ 1 am exempt under Sec. ,B a P. C. for this reason
OwnerDate
APPLICATION DATE VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
D 1 have and will maintain a Certificate of Consent to self-Ineura for Workers Compensation,
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
Building/.�/3�I•�`Y�^S
permit lave
J
Seismic
❑ I have and will
and Worker's Compensation Insurance, as required by Section 0l
the performance
-the Labor Code, for the performance of the work for which Ih19 permit le Issued. My Workers
Worker's
Com .111 Ins nc terrier nd Policy mbar ere'
�4•
Total n_
— 11
PERMIT AUTHORIZATION
DATE
Carrier Po No.
CERTIFICATE OF E% 1PTION FROM WORKERS'
COMPENSATION INSURANCE NCO
(This section need not be completed If the permit Is for one hundred tlollars (s10o) or less.)
7o Q s•
/ 7> 7t -s144/
I certify that In the performance of the work for which this permit Is Issued. I shell not emptoy
any In become
person any manner so as to subject to the Workers' Compensation Laws of Call.
All roof^ shall be inspected prior to any roofing material being
forts.
installed. If a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
subjectOloo Eth WAorrlers' APPLICANT:
atio provimakinsions of thtificate of e Labor Code, you Exemption,
uforthwlitlhbecome
comply
y comply
Applicant understands and will comply with all non point
p y
with such provisions or this permit shalQbe doomed revoked.
source regulations.
I certify that I have read this eppllcatlon 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
All roof n StO be Cl S C" rbetter.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
ep
/
� 1 ILI
(We) agree to
(We) agree to neve, Indemnify and keep harmless the City of Cupertino against liabilities,
'v l v' 7L�
judgments, coats and expenses which may In any way accrue against said City In consequence
SIGNAT RE OF APPLICANT DTE
of the granting of this permit.
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