R 4641 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R— 4641
INSPECTION DIVISION PERMITEXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1e0 DAYS OF PERMIT ISSUANCE OR
WI180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
O3� RESIDENTIAL COMMERCIAL OTHER
OWNS 'S HAZARDOUS FIRE AREA
YES ❑ If yes-I understand that a Class A
NAM V-iGXJI S� root assembly is required.
NO Initial I.C.B.O.N
ADDRESS �v EXISTING ROOF COVERING
PHONE r " NUMBER OF EXISTING COVERINGS '
CONT TOR' p•� r�-�
NAM r e5 �IJQT TO BE REMOVED_.x TO BE RETAINED S�—
ADDRESS �O �1/n�� ,,,, (�� TYPE OF ROOF COVERING
CIN 87JP1 J - -1�✓�,� 1�3�� - EXISTING
PHONE 1\"I,l BUILT-UP ROOF ❑
LICENSE El
ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION RT A A e Pillpq
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES L_ LLl
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect. WOOD SHINGLES r oop[
License Cleee Lic.Number i rl N 9 Wa96
Date�' 1 Convaola OTHER(SPECIFY)�ITY OF CUPE�,
R-BUILDER CLA ION NO
PROPOSED
I hereby l irm that I exempt from the Contractor's License Law for the following reason.
(Sac.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,after,improve,demolish,or repair any structure,prior to its Issuance,also requires the BUILT-UP ROOF ❑
applicant for such Permute lila a signed statement that g itlicenaetl 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 civil penalty of not more than 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 Proas-
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.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) Elnot 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 Contractor's License Law does not PROVIDE LC.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 Contracmr's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 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:
have and will maintain a of the
of Consent to self-insure for Worker's Compensation,which
this gl L�i O Budding
as provided for by Section 3]00 of the Labor Code,forme performance of the work for which thio 'L I' ^� 666
permit lav and I /l 7 1 Seismic
❑ have entl will maintain Worker's Compensation Insurance,as requiredsu Section 3700's , ��-•aaac.JJll//
-theC. Labor Code,for the partormance of thew rk for which ihla permit Is Issued.My Worker's J/
Co n Insur notice,r lid Policy nu bar are: Tom,_ ► 1 /yp Total
cerde� og PorieyhN 7-11 W1b PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed if the permit is for one hundred dollars($100)or less.)
I certify that in the pedormence of the work for which this permit Is Issue4 shell not employ
any person in any manner so as to become subject to the Workers'Compensation Laws of Cell- Allroof^shall be lnspecte prior to any roofi g ma sing
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: If,after making this Certificate of Exemption,you should become Applicant understands and will coin
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pp ply with all non point
with such provisions or this permit shallibe deemed revoked. Source regulations.
I certify that I have read this application and state that the above Information Is correct.)agree
tocomplyurposlciryentl county ordinances and stele laws relating lobuilding Construction,and AIIAII roofng beC "Or better. 1
hereby authorize representatives indemnity
of mos city to enter upon they of Cupertino
a properly for is,
hereby
purposes. t�-"�JJ'—�'-=_—�I—1
(We)agree costs save,indemnify entl keep harmless the Clry a1 Cupertino against Ilabilitias, A
o�he granting of this permit.and ec which may In any way accrue against said City-Iconsequence SIGNATURE OF APPLICANT DA E
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 CnPV '