R 4892 ERT
APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 489
2
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
Wr
WITHIN DAYS PERMIT ISSUANCE OR
180 DAYSS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
ADDRESSSIIJJ,�, /^� ��n ./
CJG9 1.7�T`T� HII.C,r p(,(�QJ RESIDENTIAL `" COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
Vtn n 1 Yi YES ❑ If yes—I understand that a Class A
NAME - roof assembly is required.
NO ❑ Initial I.C.B.O.F
ADOREss gnn�G 6pep [ rti u-c EXISTING ROOF COVERING
PHONE dS:L S 1 —1 - NUMBER OF EXISTING COVERINGS 3
CONTRACTOR'S
NAME /PnIl D84. 00J_
III TO BE REMOVED TO BE RETAINED
ADDRESS OO, �r I TYPE OF ROOF COVERING
CITY a ZIP�CJ�D h 1 KOlu'tC.Q.f.l� F.-GL-�I--� {7P� EXISTING
PHONE 369-74"i BUILT-UP ROOF ❑
• LICENSE 481
NUMBER oZ.� ASPHALT SHINGLES ❑
CJ
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter g(commencing with Section WOOD SHAKES ❑
7000)aof Division 3 of the Business and Professions Code,and my license le In full force end
Ucm. WOOD SHINGLES
C39 (0g8l�a-4
❑
License Cleea Llc.Number
Data G Convector Ii GB4,0ji OTHER(SPECIFY) �C
OWNER-BUILD DECLARATION PROPOSED
I hereby affirm that I am exempt from the Co 1 ctor's LlcensgA%w lot the following reason.
(Sec.7031.5,Business and Professions Cotle: y city or cpQnry which requires a permit to
construct,alter,improve,demolish,or recall r any.a cture)pd' to Its Issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement ahbd Y Icensed pursuant to the provisions
of the Contractor's License Lew(Chapter g(comm dingp Ith Section 7000)of Division 3 of the
Business and Professions Code)or, at he le ex I thhrafrom and the basis for the alleged ASPHALT SHINGLES ❑
axe
mption.Any violation of Section 7D .5bya p ca for a permit subjects the applicant to
e civil penalty of not more than4ve hu re s($ .):
❑I,asownerofl of erry,army wh wages as their sole compensation,will do WOOD SHAKES ❑
the work,end the at at re to N a offered for sale(Sec.7044,Business and Profea-
alone Cotle:The C tie t r c Le does not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon, a cfi work himself or through his own employees,provided that ❑
ouch Improvements e n jan ed or offered for sale.II,however,the building or Improvement
ie sold within one ye dr, pletion,the owner-bulldor will have the burden of proving that he did OTHER(SPECIFY)
Improve ISI
not builtl or far rpose of sale.).
❑I,as owner of the property,em exclusively contracting With licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's 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 contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B$P.C,Ion this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
1 hereby affirm under penalty of perjury one of the following declaration:
have and will maintain 37 0 of the Labor
of Consent to sell-Insure for Worker's Compensation,
this
�I Building
!' ae provided for by Section 3700 of the Labor Code,for the performance of the work for which this �7 .! tN
permit' Issued. `✓` Seismic
Lg1 have end 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 Warker'e k
Compensation Insurance carrier antl(Policy number are: x' 7 ^ Total
Carrier sJ�Qle Ji Lkl Policy NoJ_'iM -7Z— Cam PERMUF691THORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need not be completed it the permit Is for one hundred dollars($100)or lees.) t./ 19
I certify that in the performance of the work for which this permit Is Issued,I shell not employ r
o xt
any person In any manner so as to become subject to the Workers'Compensation Lew$of Cell. All roofs shall be )Zerrfted prior o any roof g ma ria eing
fornia. installed. If a roof Is (fistplied without first obtaining an
Date Lo-3�1p Applicant inspection,i agree to remove all new materials for inspection.
subjects to the Workers'CompeE TO APPLICANT: f,after nsation provisi n len f Lel r Code,Exemption.
must forthwith thwlitlhbecome
comply Applicant understands and will comply with all non point
with such provisions or this permit shall be de ea revpka . 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 class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes.
(We)agree to save,Indemnity and keep harri the City of Cupertino against liabilities, 01U -3
jud menta,costa and expenses which may In any way accrue against said City In conse
0
uence .
of tRe granting of this permit NATO OF 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 COPV '