R 4938 PERMIT R_ 493
8
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
90
X
0IO -3Tc/- u u 14 (4L ��r RESIDENTIAL ' ` COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
a v( " z* YES E3 If yes-I understand that a Class A
NAME (� roof assembly is required.
NO ❑ Initial - I.C.B.O.If
ADDRESS S EXISTING ROOF COVERING
PHONE or,�3 atl33 NUMBER OF EXISTING COVERINGSCONT /
NAMERACTOR'SA F ���7
TO BE REMOVED�TO BE RETAINED
ADDRESS K !63 C Lam! P U-W 9 TYPE OF ROOF COVERING
CITY BZIP EXISTING
PHONE 2 its S�U� BUILT-UP ROOF
LICENSE as y�6
NUMBER ASPHALT SHINGLES ❑
LICENSEDdunderCONTRACTORS DECLARATION ❑ `/
hereby iaffirmnion that em licensed and
Pr provisions of Chapter B(commencing with f Section WOOD SHAKES
70001 0l Division 3 of the Business entl Prole961ons Code,and my license Is In lull kroe and /
effect,h WOOD SHINGLES ❑ £C
Lie has Close �-v Llc.Number
Deo 8� ( 3 contractor / nA• OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Professions Coda: 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 le licensed pursuant to the provlelone
•
at the Contreotors License Law(Chapter a(commencing with Section 7000)of Division 3 of the
Buelneee 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 then five hundred dollars($500),):
❑I,as owner of the property,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.
alone 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
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 Mr purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sac.7044,Business and Professions Coda:The Contractors Llconse 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 contractogs)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
[:11 am exempt under Sec. ,B 6 P.C.for this reason
Owner Da
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury are of the following declaration:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Building
p:rp ,df.r by Section 3700 oI the Labor Cotle,lorthe performance of the work forwhich this ,/, g
per or Code, Seismic
ued
have and will maintain Workers Compensation Insurance,as,required by Section 3700 of 0 '�� 9�
the Labor Coda,for the performance of the work for which rale permit Is leauatl.My Workers O
Compensation
'l/n�eure�nce carrier and Policy umber ere: �{ Total
Carrier • ' ' ' `-' Popsy No.d6 9X-900 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.
(This section need not be completed It the permit is for one hundred dollars(5100)or lase.)
I certify that In the performance of the work for which this permit Is Issued,I shall not employ
any portion in any manner so as,to become subject to the Workers'Comp°neatlon Laws of Calf All roofs shall be inspected pr any roofing material being
fornia, r installed. If a roof is instal ed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should became Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Coda,you must forthwith campy
with such provisions or this permit shall be deemed 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 totaling to bulldIng construction,and All roof coverings to b C "C"Or better.
hereby authorize representatives of this city to enter upon the above-menllonetl property for In. /I
spection purposes.
(Wen apse to save,Indemnify and keep hay way ins City ai Cupertino epelnet liabilities.
ence !J
judgments.costa and expenses which may In any way accrue epelnet said Clry In consequence
oIthe granting of this permit. SfGNATURE OF APPLICANT 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