R-46400
0
OFFICE COPY
PERMIT R_ 4 6 4 0
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
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
NAM OILYES
If yes— I understand that 81
roof assembly is required. C )`
NO E]Initial - \ \J.C.B.O. A
EXISTING ROOF COVERING
ADDRESS
NUMBER OF EXISTING COVERINGG
�
PHONE
CO A '
(
TO BE REMOVED TO BE RETAINED
NA
TYPE OF ROOF COVERING
ADDRESS
C" & ZIP
EXISTING
1
PHONED
BUILT-UP ROOF ❑
NUMBER
ASPHALT SHINGLES El
WOOD SHAKES
LIC NSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000) of Divi�siness and Professions Code, and my license Is in full force and
-
effect.
CYl
WOOD SHINGLES ❑
License C.A.— Lic. Number
OTHER (SPECIFY) ElContracto
Date r
N BUILDER D 2TI N
PROPOSED
I hereby affirm t at em ex p Irom the Coniractofs LI ansa Law for the kllowin res
(Sec. 7031 .5, Business and Professions Code: Any city or county which requires a par o
q
construct, alter, improve, demolish, or repair any structure, prior to Its Issuance, also requires in
BUILT-UP ROOF 4
applicant for such permit to lila a signed statement that he is licensed pursuant to the provisions
O C�
of the Contractor's License Law (Chapter 9 (commencing with Section ]000) of Division 3 of the
C
Business and Professions Code) or that he is exempt therefrom and the basis for the alleged
for the to
ASPHALT SHINGL�S j
exemption. Any violation of Section 7031.5 by any applicant a permit subjects applicant
e civil of not more than five hundred dollars ($500).):
17
Y011
penalty
❑1, as owner of the property, or my employees with wages as their sole compensation, will do
WOOD SHAKES uu)u S
the work, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Profes-
y�Uj
sions Code: The Contractor's License Lew does not apply to an owner of property who builds or
WOOD 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 -Wilder will have the burden of proving that he did
OTHER (SPECIFY)
not build or improve for purpose of sale.).
I, as owner at the property, am exclusively contracting with licensed contractors to construct
the project (Sec. 7044, Business and Professions Cotle: 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 contractords) licensed pursuant to the Contractor's License Law.
PROVIDE MFGR. INSTALLATION SPECS.
❑ 1 em exempt under Sec. ,B & P. C. for this reason
Owner Date
APPLICATION DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
�2_11q�
Buildines
I hereby affirm under penalty of perjury one of the following declaration:
of Consent to Performa for of the oCompensation,
❑ I have and will maintain a Of the
provided lardy ill main ain a of the Labor ansae the pednsure f rW rk work tm whish n,permit
is issued.
Seismic
p and will maintain rkeraCom nsation Insurance, as required by Section W 1
the dor ode, to the p _4a ands of the ore for it/s�ri �//�/)/ y ars
Com ns a and Polity n ober are. 111V
Total
Carrie Po a. fly
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.Q
(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 shall not employ
any person in any manner so as to became subject to the Workers' Compensation Laws of call-
All roofs shall be inspected prior to any roofing material being
fornia.
installed. If a roof is installed without first obtaining an
Data Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It, alter making this Certificate of Exemption, you should become
Applicant understands and will comply with all non point
subject to the Workers' Compensatlon provisions of the Labor Code, you must forthwith comply
with such provisions or this permit shell be deemed revoked.
Source regulations.
sitestatehat the
applicationstatethattheaboveinfatuation is correct .Iagree
wsinfbuilding
I certify That I have readthisordinances
All lob
and
to comply with allhcityave and county and relating construction, and
ro verinQS
C SSJrhereby
authorize representatives of this city to enter upon the above-mentioned property for in-spection
purposes.(We)
agree to save, indemnify antl keep harmless the City of Cupertino against liabilities,
judgments, costs and expenses which may in any way accrue against said City in consequence
SIGNATURE OF APPLICANT DAT
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