R-4644•
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PERMI R- 4 6 4 4
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
^
7.227L� 1 w�
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
y
I understand that a Class A
VES ❑ If yes that
_ ��
NAME— �_� iii ``
rootassembly is required
s
NO Initial I.C.B.O. k
EXISTING ROOF COVERING
ADDRESS
NUMBER OF EXISTING COVERINGS
PHONE
CONTRACTOR'S
b`��y�f
TO BE REMOVED TO BE RETAINED
NAME l/�
P COVERING
ADDRESS
CITY & ZIP
EXISTING
PHONE
BUILT-UP ROOF ❑
CENSE
NUMBER
ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
hereby affirm that I em licensed under provisions of Chapter 9 (commencing with Section
WOOD SHAKES ❑
700 0) of Division 3 of the Business and Professions Code, and my license Is In lull force and
effect.
WOOD SHINGLES ❑
License Claes Lic. Number
OTHER (SPECIFY) ❑
Date Contractor
OWNER -BUILDER DECLARATION
PROPOSED
I hereby affirm that I am 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 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 SHINGLES
exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civll penalty of not more than five hundred dollars (8501
WOOD SHAKES ❑ -
❑ 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.
sions Code: The Contractor's License Law 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. II, however, the building or Improvement
-
Issoldwithinoneyearolcompleticn, the owner -builder will have the burden of proving that he did
OTHER (SPECIFY) ❑
not build or Improve for purpose of sale.).
C1 1, I, 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.
apply to an owner of property who builds or improves thereon, and who contracts for such projects
with a contrectogs) licensed pursuant to the Contractor's License Law.
`71
PROVIDE MFGR. INSTALLATION SPECS.
am exempt under Sec. ,B & P. C. far this reason
Owner - Date
APPLICATION DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the followingdeclaration:for
Wo
❑ I have and will maintain a Certificate of Consent to sell -insure for Worker's Compensation,
Building
as provided for by Section 3700 of the Labor Coda, for the performance of the work for which This
permit Is Issued.
Seismic
❑ 1 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
Total
Compensation Insurance carrier and Policy number are:
Carrier Policy No.
PERMIT AUTH(ARIZATION
DATE
CERTIFICATEEN COMPENSATION SURANMWORKERS'
COMPENSATION INSURANCE N C.)o
1
(Thio section need not be completed 11 the permit Is for one hundred tlollars Sit 00) 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 become subject to the Workers' compensation Laws of Can-
All roofs shall be inspected prior to any roofing material being
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: 11, after making this Certificate of Exemption, you should become
Applicant understands and will comply with all non point
PP P Y P
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
with such provisions or this permit shall be deemed revoked.
Source regulations.
I certify that I have read this application and slate that the above Information Is correct. ) agree
to comply with all city and county ordinances and stale laws relating to building construction, and
All roof coverings to be class " Bitter.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes.
(We) agree to save, Indemnify and keep harmless the City of Cupertino against liabilities,
judgments, costs and expenses which may In any way accrue against said cry In consequence
$IG RE 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