R 48840
OFFICE COPY
APPLICATION FOR CITY OF CUPERTINO NUMB R R- 4884.
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 LASTCALLED INSPECTION.
BUILDING ADDRESS
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RESIDENTIAL " COMMERCIAL OTHER -
OWNER'S.
HAZARDOUS FIRE AREA
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VES ❑ If yesI undersnd that a Class A
NAME
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NO Initial I.C.B.O. N
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EXISTING ROOF COVERING
ADDRESS / i
NUMBER OF EXISTING COVERINGS
PHONE 39 o81-7
CONTRACTOR'S
NAME' CR/ / A G �OCh n� 1.��: L
TO BE REMOVED TO BE RETAINED
ADDRESS -7(/6 ,ten d� /
TYPE OF ROOF COVERING
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CITY B ZIP Aa / „ut, ! ` 7
EXISTING
/tr, y
3� �7
PHONE l T
BUILT-UP ROOF ❑
LICENSE
NUMBER (O 2
ASPHALT SHINGLES ❑
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WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 8 (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license Is In lull force and
enec.
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License Class 39 Lic. Number Z V Z
WOOD SHINGLES , ❑
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OTHER (SPECIFY)
Data ���7t6 Cantralor
OWNER -BUILDER DECLARATION
I hereby that I from
PROPOSED✓/r/,rU
affirm em exempt the Contractors License Law for the following reason.
(Sec. 7031.5, Business and Professions Code; Any city or county which requirao a permit to
construct, alter, Improve, demolish, or repair any structure, prior to its Issuance, also requires the
applicant for such permit to file a signed statement that he is licensed to the
BUILT-UP ROOF 4.0 ❑
pursuant provisions
of the ss and Contractor's License Lew (Chapter (co meniff with Section 7000) of
Bualnaae and Professions Code) that the 3 of the
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or for
hers mpt therefrom antl the basis for the alleged
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exemption. Any violation of Section 70,71$ by. appllcanl for a permit subjects the applicant to
a civil than five hum
ASPHALT SHINGLES dT7iYY1
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penalty of not more e o (5500).):
O 1, as own the pr rry;er b wages as their sole compensation, will do
WOOD SHAKES //yyrt
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the work, antl the simctu Is nofl r all for sale (Sec. 7044, Business and Proles-
-
sions Cotle: The Conim w aes not apply to an owner of property who builds or
Improves thereon, andaha a suctrwork himself or through hie own employees, provided that
WOOD SHINGLES ❑
such improvements are nolldle deb or offered for eels. II, however, the building or improvement
Is sold within one year of co�,pletion, the owner -builder will have the burden of proving that he did
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OTHER (SPECIFY) rLG]��r/ (, C•I-ir9
not build or Improve for purpose of sale.).
01, 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. b�
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 Contractor's License Law.
❑ I em exempt under Sec. ,B 8 P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner Data
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION
PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
a..rs
01 have and will maintain a Certificate of Consent to self -Insure for Workers Compensation,
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BUIId
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
permit Is Issued.
01 have and will maintain Worker's Compensation Insurance, as required by Section 3700 of
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Seismic 070
the Labor Cotle, for the performance of the work for which this permit Is Issued. My Worker's
I I
Compensation I.nJq.,ur�enceQcartler antl Polley number are:
Carder �I /j'�` �aO Policy No. " 7— �4
Total
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed It the permit is for one hundred dollars ($100) or less.)
I certify that In the performance of the work for which this permit is issued, I shell not emptoy
any In become Workers'
All roofs s al be inspected prior to any roofing material being
person any manner so as to subject to the Compensation Lowe of Cog-
fornia.
installed. If a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If, alter making this Certificate of Exemption, you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
Applicant understands and will cora
pP ply 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 stale that the above information is correctI agree
to comply with all city and county ordinances and slate laws relating to building construction, and
All a ng obs class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property far In-
spection purposes.
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(We) agree to save, indemnity and keep harmless the City of Cupertino against liabilities,
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judaMonte, costs and expenses which may In any way accrue against said City in consequence
onha gram ng of this permit.
SIGN TU E APPLICANT AT
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