R-4646•
•
OFFICE COPY
PERMIRR- 4646
APPLICATION FOR CITY OF CUPERTINO NUMB
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1B0 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
/?717
RESIDENTIAL COMMERCIAL OTHER
OWNERS
HAZARDOUS FIRE AREA
r
YES ❑ If yes I mites that a Class A
NAME �/n L: T �Vr7A
roof ass is required
is required.
NO Initial LC.B.O. It
�%� ��H�= 7Z
EXISTING ROOF COVERING
ADDRESS � % 02
PHONE — Z p/ O
NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
n / �
/1"���-� %�&A✓A
TO BE REMOVED TO BE RETAINED
NAME .�/✓57�4��i4'T/O
OF ROOF COVERING.
ADDRESSTYPE
c,TYBZIP -77// 7 �A/Z.�/SON ST' S%,�; C4 �5
EXISTING
-777 Z 7�1
PHONE ye t — —/
BUILT-UP ROOF ❑
LICENSE
NUMBER :0—YS-2- `
ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
-
WOOD SHAKES ❑
7000) of Division 3 of the Business and Professions Code, and my license Is In full force and
effect.
Q/�y
Class Uc. Number 91 ` &/
WOOD SHINGLES ElLicense
/�— 0,7— 12.E
OTHER (SPECIFY) ❑
Date Contractor
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 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 civil penalty of not more than five hundred dollars I Soo).):
WOOD SHAKES E]❑
I, 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 Proles
alone Code:The Contractor's License Law does not pply to an owner of property who builds or
WOOD SHINGLES ❑
Improves thereon, and who does such work himself o through his own employees, provided that
such improvements are not Intended or offered for s If. however th tllnB or improvement
Is sold within one year of completion, the Or- it sr Ill have tf r n fprovingthathedid
OTHER (SPECIFY) ❑
not build or Improve for purpose of sale.). �`'/�lV
❑ I, as owner of the property, am exclusi C r tl Wit��LLllcena Contractors to Construct
the project (Sec. 7044, Business and Protea Co : eAomractor's License law does not
PROVIDE I.C.B.O. REPORT NO.
applytoanowner of pra arty who bull I Dues th ,end who contracts for such projects
wuhaconimctor(a)Iice ed par n t C ntrgslbreL ansa Law.
PROVIDE MFGR. INSTALLATION SPECS.
I am exempt untle c ,B 8 P. C. for this reason
OwnerData
APPLICATION DATE
VALUATION
PERMIT FEE
RKER'S COMPENSATION DECLARATION
_ -� ,-..015
I hereby affirm under p Ity of perjury one of the following declaration:
❑ I have and will maintain a Certificateof Consent to salt -Insure for Worker's Compensation,
Building
as provided for by Section 3700 0l iia Labor Code, for the performance of the work for which this
ofthe
ermit is Issued.
OCTO 23
/ �
Seismic —�
❑ I have and will maintain Worker's Compensation Insurance, as required by Section 3700 of
for Is Issued, My Workersn
199
the Labor Code, for the performance of the work which this permit
Total
Compensation Insurance carrier and Policy number are:
.dI
Carrier &�1%ns�•ZecR�u'4v Policy NOVA
PERMIT'AUT,HORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORK RS'
COMPENSATION INSURANCE N.C.[]
to I
CI
(This section naotl not be completed If the permit is for one hundred dollars fill 00) 00)o or less.)
4`
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 Cali.
All roofs shall be inspected prior to any roofing material being
fornia.
stalled. If a roof is installed without first obtaining an
Date /Q_ 1-3 !9J Applicant
inspection, I agree to remove all new materials for inspection.
Applicant understands and will comply with all non Dint
pP P Y P
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become
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 state that the above Information Is correctI agree
to comply with all city and county ordinances and state laws relating to building construction, and
All roof coverings to be class "C" or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes.
Ze
(We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities,
�� �Q —
judgments, Costs and expenses which may In any way accrue against said City In consequence
SIGNATURE OF APPLICANT DATE
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
OFFICE COPY