R 4848 PERMIT R_ 4848
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 LASTCALLED INSPECTION.
BUILDING ADDRESS
�k{�
30 ��S714& e7 RESIDENTIAL_L� COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
NAME10��Prel?/r YES ❑ It yes—I understand that a Class A
z D'G� t}//A {/ T roof assembly is required.
!/`a/O / //` v/!/ �/ NG Initial LC.B.G.N
�OZ
ADDRESS_ EXISTING ROOF COVERING
PHONE! ��% / NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S��ld
NAME �/"/" A/�4e;� TO BE REMOVED TO BE RETAINED
ADDRESS S7� /�AYJ�L� sr TYPE OF ROOF COVERING
CITY&ZIP —' G /y•" !i
' EXISTING
PHONE 5f1l 7 -69 BUILT-UP ROOF
❑
LENSE
NUMBER � ASPHALT SHINGLES
NUMBER J (S� / ❑ '
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES
7000).11 Division 3 of the Business and Professions Code,and my/license is In full force and
eat.
Li �✓? f�� 9 ❑
Llcenea Class� Lic.Number
WOOD SHINGLES
i
OTHER(SPECIFY) ❑
Date Contractor
OWNER-BUILDER DtCLARATA PROPOSED
I hereby affirm that I am 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,altar,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 B(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
e civil penalty of not more than live hu dfa gera(5500).): WOOD SHAKES
❑I,as owner of the props or nay mpl ewith wages ea their sola crompensation,will do ❑
the work,end the etructur gl'inlen d r ietl for eels(Bac.7044,Business and Proles-
aloneCod The Contrac r'eLicenseL t apply to an owner of property who builds or WOOD SHINGLES
improves thereon,antl h d e 1 sell or through his own employees,provided that ❑ /�
such Improvements are te0 d r off' for sale.If,however,the building or Improvement
IS Bold within one year o qo Is on.the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ® G
not build or Improve for purpose ol.sale.).
Ores owner of the properly;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 bonds or Improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
[_1I em exempt under Sec. ,B&P.C.for this reason
ownerDate
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
1 hereby affirm under penalty of perjury one of the following declaration: INAY
E]I have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, r� 7/9 Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this 19%permit Is Issued.
• ❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of l yr txVh �s'S� Seismic
the Labor Code,for the performance of the work for which this permit is Issued.My Workers 2/
Compensation Insurance carrier and Policy number are: U • Total
Carrier , Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' 01Z Z
COMPENSATION INSURANCE N.C.]
(This section need not be completed If the permit Is for one hundred dollars($100)or lase.)
I coolly 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'Compo eallon Law&of Cali. All roofs shall be inspected prior to any r oting roLatellitY being
fornia. I installed. If a roof is installed without first obtaining an
Date_f 7 �G Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: ll,after makln this Certpli ate of Exemption,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP p y p
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 coverings to be cl 'C"or better.
hereby authorize representatives of this city to enter upon the above-mentloned property for In-
spection purposes. �7
(We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities, eZZ
judgments,costs and expenses which may in any way accrue against sold Cit,In ronsequence
of the granting of this permit. jI9INATURE 9F 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