R 4771 APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 4771
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
OWNERS /' ,)00HAZARDOUS FIRE AREA
NAME MaAU
ry
AW ,4W 4 YES ❑ If yes—I understand that a ClassA
roof assembly Is required.
NO ❑ Initial I.C.B.O.k
ADDRESS I I:2y7 A. Q4±_etdJ CT EXISTING ROOF COVERING
PHONE SS NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME /0 TO BE REMOVED TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP
EXISTINGPHONE
Fla,
LICENSE BUILT-UP ROOF P41/&W /*
NUMBER ASPHALT SHINGLES 3 d
LICENSED CONTRACTORS DECLARATION e
I hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES
7000) B
effect.of Division 3 of the Business and Professions Code,and my license le In full force antl
WOOD SHINGLES
License Cleve Lie.Number
Date Contractor OTHER(SPECIFY) ❑
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,0180 requires the BUILT-UP ROOF El
for such permit to file a signed statement that he Is licensed pursuant to the provislons
of the Contractors License Law(Chapter g(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 civil penalty of not more than five hundred dollars($500).):
❑l,as owner of the properly,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes.
sions Code:The Contractors 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.If,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusive y 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 contractorts)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
C]I am exempt under Sec. ,B&P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to sell-Insure for Workers Compensation, 4/ BUllding
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this in
permit Is issued. r SBISrITIC
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of O
.the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's EB 1 1996
Compensation Insurance carrier and Policy number are: 'Total
Carrier A Policy No. PERMITTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' LI
COMPENSATION INSURANCE
(This section need not be completed If the permit to for one hundred dollen($100)100)or leas.)
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 Cell- I roots shall be inspected prior to any rooting material being
f°`nia. installed. If a roof is installed without first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
subject to the ICE APPLICANT:
orks ee Co pel,after ns tion provlelons of thethis icate of Laborr Code,yyolu must foinwith amply Applicant understands and will comply with all non point
with such provisions or this permit shaipbe doomed revoked source 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 roof coverings to be class°(moi°or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In
purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against Ilabllltles.
of the granting of this perdgments,costs and it expenses which may In any way accrue against said City In consequence SIG ATU OF APPLI ANT DATE
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