R-4584 PERMIT
- APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 4584
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (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 t
�977
iif`C/jj//��
RESIDENTIAL COMMERCIAL OTHER
OWNER'S ' HAZARDOUS FIRE AREA
- \ YES ❑
If yes I understand that a Class A
NAME 1 Q%k C `�--�/V/ roof assembly is required.
NO Initial I.C.B.O.N
ADDRESS t EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS T PE OF ROOF COVERING
CITY&ZIP
EXISTING
PHONE BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES El
700
of Division 3 of the Business and Professions Code,and my license is In full force and
effect. WOOD SHINGLES El
License Class Lic.Number
Date contractor OTHER (SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
IS 7031.5.Business and Professions Code: Any city or county which requires a permit to
construct.alta,Improve,demolish,or repair any structure,prior to its issuance,also requires the BUILT-UP ROOF PA 0n Elapplicant 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 SHIPZy
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to Ifs 1
a civil penalty of not more than five hundred dollars($500).): WOOD SHAKE19g�
❑1,as owner of the property,or my employees with wages as their sole compensation,will do .K, fS
the work,and the structure Is not Intended or offered for sale(Sec.9044,Business and Profes-
.
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES ��NEHTI
Improves Matson,and who does such work himself or through his own employees,provided that NQ El
such Improvements are not Intended or offered for sale.If,however,the building or Improvement
Is sold within one year of completion,the owner-bullder will have the burden of proving that he did OTHER(SPECIFY) ❑
y
or Improve for purpose of sale.).
s owner of the property,am exclusively contracting with licensed contractors to construct
ct(Sec7Businessand ProfessionsCeTheComrectola License lawof ..not PROVIDE LC.B.O.REPORT NO.
an ownerofpropertywho buildsrimprv..Incision,antl who convectst ...ch project.ntractor e)Ilcensetl puts.am to the Contractor'.License Law. PROVIDE MFGR. INSTALLATION SPECS.
F7 am exempt under Sec. ,B 8 P.C.for this reason
Owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to sel Insure for Worker's Compensation, Building 6"x
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this '
permit Is Issued. Seismic
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's
Compensation Insurance carrier and Policy number are: Total
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.p
(This section need not be completed If the permit is for one hundred dollars($100)ar less.)
I certify that In the performance of the work for which this permit is issued,I shall not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Cali. All roofs shall be inspected prior to Brij roofing dateriAl being
fornia. installed. If a roof is installed withbut 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 Applicant understands and will com I with all non point
subject h the Workers'Compensation h provisions d the kebor Code,you must forthwith comply PP ���
with such provisions or this permit shall be deemed revoked. SOUfCe 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 All root Verin sto be class"C"orb
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection
(Wit) purposes.
(Wit)agree to save,indemnity ees and keep harmless the City a of Cupertino said
against liabilities,
judgments,coats and expenses which may in any way accrue against sell Clry In consequence I ATU E O APPLICANT DATE
• of ins 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY