R-4833 PERMIT R_ 4833
APPLICATION FOR CITY OF.CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
WI180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
M73b AM1461i DR,
CuFERT'rA(O r4- RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
NAME C HEMG .FS ML YES ❑ rotof assembly staequhed. Class A
NO ❑ Initial LC.B.O.H
ADDRESS 19130 -4-MHCIZS7- DR EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS
PHONE err-L(As
CONTRACTOR'S O
I�.}NNkI1S G oN ST'RJ Ci=O N TO BE REMOVED TO BE RETAINED
NAME
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP )0o7-9 '74rCH W,I-Y
EXISTING
PHONE 21"3-138`6 BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGL ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 0 of the Business and Professions Code,and my license is in full lona and
effect.
WOOD SHINGLES
License Class 13 Lint.Number b to 4 99 (P
Date 19122_ Contractor b"hNIdY LE"t OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED A I D
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 AUG 2 21���
construct,alter,Improve,demolish,or repair any structure,prior to its issuance,also requires the BUILT-UP ROOF
applicant for such permit to fila a signed statement that he Is licensed pursuant to the provisions
cf the Contractors 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 SHINGLE u.n Lr1 I INU
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to III Vf V
a civil penalty of not more than five hundred dollars($500).): WOOD SHAKES El
theas 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 Profes-
sions Cade:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES El
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) TrL L`
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct 2 09 p
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO. .J
apply to an owner of property who builds or improves thereon,and who contracts for such projects
with a contracmgs)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
[:]I am exempt under Sec. ,B 8 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:
❑I have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this /
permit is issued. x Z (Z (1�7V 0 Seismic
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
the Labor Code,for the performance of the work for which this permit is issued.My Worker's
'Compensation Insurance carrier and Policy number are: Total
Carder 67011-D£r1 9„44IJ. PolicyNo.NWU 424to ?-60 PERMIT AU HORIZATION 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.)
1 certify that in the performance of the work for which this permit Is issued,1 shall not employ
any person In any manner so as to become subject to t orkera compensation Laws of can- All roe r.shall be inspected prior to any roofing material being
tesla. / 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,yo should become Applicant understands and will I with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP comply Y P
with such provisions or this permit shalCbe deemed revoked. source regulations.
I certify that I have read this application antl 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 verings to be class"C"or better.
hereby authorize representatives of this city to anter upon the above mentioned property for spection
(We)agree(We)agree to save,Indemnify and keep harmless the City of Cupertino against Ilabllitles, O
judgments,costs and expenses which may In any way accrue against said City in consequence SIGNATURE OF APPLICA T DATE
of the granting of this permit.
PRE-INSPECTION: PLYWOOD: IN-PROGR SS:
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 _