R 4790 PERMIT R_ 4 7 9 0
APPLICATION FOR CITY OF.CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
'
WITHIN 180 DAVE OF PERMIT ISSUANCE OR
WI180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
1 n r) O v "`^ ' RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
., . VES ❑ If yes—I understand that a Class A
NAME J '✓ roof assembly is required.
NO Initial I.C.B.O.N
ADDRESS I EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS 1 3
CONTRACTO 'S
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS 0 1M P TYPE OF ROOF COVERING
t CITY&ZIP' 4 'V) 1 - 1501
1 " l9
PHONE_40 V � ) ' - 1 50ry/�V c b B -PROOF ❑
f LICENSE Ll_LL Or
NUMBER I_ LV ASPHALT SHINGLES
�L \\ 1 V7 —1
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Cotle,and my license Is In full force and
enact. WOOD SHINGLES X
License Clas Lie.Number
Date COT llaCfofOTHER(SPECIFY) 1:1OWNER-BUILDER DECLARATION• PROPOSED
I hereby affirm that I am exempt from the Contractors License Law for the following reason.
IS
7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,eller.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 Lew(Chapter a(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 -14
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).):
01,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(Sac.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 awn 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) El
build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors 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 contractor(s)licensed pursuant to the Contractors License law. PROVIDE MFGR.INSTALLATION SPECS.
F1 am exempt under Sec. ,B a P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
p I g�
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's 69 Compensation, D BUIIdI _
as provided for by Section 3700 of the Labor Cade,for the performance of the work for which this '] g
permit Is issued. MAR d �j O Seismic
❑I have and will themaintain Workers Compensation which Insurance,as requiredsu d.My 3700 s 1996
the Lea r Code,icor the performance of the work icor which this permit Is Issued.My Workers
s. Com so5Inytrep�cards no Polley nerPbor are: n _ C Total
errler \/ Tlblya. •V-r_r�Y� Policy No L ,S 1 �I ' 'PERMIT'AL RIZATION DATE
CERTIFICATE OF EXEMPTION FROM RKERT
.s COMPENSATION INSURANCE N.C.(]
(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 become subject to the Workers'Compensation laws of Cell- All roofs shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Dale Applicant inspection,I agree to remove all new materials for inspection.
NOT CE TO APPLICANT: If,after making tsof Exemption, o
subject t.the Workers'Campenamlon provisions of theicate Labor Code,you must fo thwllthbecome comply Applicant understands and will comply with all non point
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 relating to building construction,and All roof COVrin to be I SSS "or tier,
hereby authorize representatives of this city to enter upon the above-mentioned property for In. r
spection purposes.
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities, s
judgmonts,costs and expanses which may In any way accrue against sold CItY In Consoquanca
of the greeting of this permit. SIGNATURE 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