R 4936 PERMIT R_ 4936
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 LAST CALLED INSPECTION.
BUILDING ADDRESS
I
1090 A fL(LAidC f'7 V� , RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
G2 C \ ` _.) IL L YES E] If yes—I understand that a Class A
NAME b V n I NO roof assembly is required I.C.B.O.N
ADDRESS2, 3 x3 9 a u FA M t T (Lid .- EXISTING ROOF COVERING
;r CSS C��hoS So
PHONE $ 3 — 33 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S ` ,^L _
' NAME A,d 4� ` oo I� I AJ �7 TO BE REMOVED TO BE RETAINED
ADDRESS �0 � X b 3 (2 ,P 9 50 0 9 TYPE OF ROOF COVERING
CITY& 1 EXISTING I
PHONE BUILT-UP ROOF ❑
LICENSE
�1
NUMBER �,Q 6 ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 0(commencing with Sectlon WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect,
❑
License Claes `�[N' WOOD SHINGLES�� Lie.Number
Dare 7 9' 9 to Contractor n OTHER(SPECIFY) ❑
OWNER-BUILDER DE RA N PROPOSED
I hereby affirm that I em exempt from the Contracto a LIC a Law for the following reason.
(Sec.7031.5,Business antl Professions Code: Any city or county which requires a permit to
construct,alter,Improve, often,or repair any st cture,prior to Its Issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed state man t t he Is licensed pursuant to the provisions
of the Contractor's License Law(Chapter a(comm n g will,Section 7000)of Division 3 of the
Business and Professions Code)or that he IS axe t erefrom and Me basis for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any ap ntor a permit subjects the applicant to
e civil penalty of not more than five hundred ollefs 0,.
❑I,aeowner of the prop rmye to I w ee as their sole compensation,will do WOOD SHAKES ❑
the work,antl the strue orr a not Intentl r for sale(Sec.7044,Business and Profen
sions Cotle:The Contrec es LiceCs not apply to an owner of property who builds or WOOD SHINGLES
Improves(hereon,antl who a himself or through his own employees,pravltletl that ❑
such Improvements ere p6 r offered for sale,II,however,the building or Improvement
Is sold within one year ol5
met
on,the owner-builder will have the burden of proving that he did - OTHER (SPECIFY) ❑
not build or Improve for p m6ss 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 contractors)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
I]I em exempt under Sec. ,B&P.C.for this reason
Owner Dale
WORKER'S COMPENSATION DECLARATION ,APPLICATION,DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: 1?
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, �T
as q,rovidedlorbySecl1on3700oftheLaborCode,fortheperformanceoftheworkto(whichthie �g�9 ' Building
perryt laveand . ��?ob
eT�Labor Code will maintain Worker's Compensation Insurance,as required by Section 3700 of y � t� $eISfI11C
ih Lobar Cotle,for the performance of the work for which this permit Is Issued,My Workers J U'('G
Compensation Insurance carrier antl Polley number are: �,/� ^r k W V Total
Carrier /T1 ��� I) PolicyNo.w9�b� CiPERMITAUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C. /7
(This section need not be completed If the permit Is for one hundred dollars($100)or lase.)
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',�pmp uon La`of call. All Too s h be inspected prior to y roofi m terial being
l l _ Q / `� installed. If a roof is installed without first obtaining an
Date / Appllc7C� Q.L/Z.CP/c.C. inspection,I agree to remove all new materials for inspection.
forsubject NOTlIoE a WorkereTO CCom Compensation proviANT: If,after me sionls of theCertificate
Labor Code,you ,you should become Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. you must forthwith comply p y
source regulations.
1 ceto rtify that have read thirtyapplication ordinancantletmethattheebove Information Is correct. agree
hereby authoy withrize
all cityrep and tabes of this city and enter upon thel ting above-mentioned
ed property
and All roof coverings to be aS�e' r better.
hereby authorize represontetivea al this city to enter upon the ebove�mentlonetl property Mr In. � � ��� p� �
spection purposes, 1�--lmLQ/1•�{ —""" '• �' at tka "a-i
(We)agree to save,indemnity and keep harmless the City of Cupertino ag9ainst liabilities,
judgments,costs and expenses which may In any way accrue against said City In consequence
. of the granting of this permit. SIUNATURE OF APPLICANT DATES -�j
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