R-4519 PERMIT
APPLICATION FOR CITY OF CUPERTINO
NUMB R R- 4 519
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
1B0 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL— COMMERCIAL OTHER
OW R'S HAZARDOUS FIRE AREA
�''�/� YES ❑ If yes—I understand that a Class A
NA 1 1 r-5. e C.17 roof assembly Is required.
NO" Initial I.C.B.O.It
ADD 'TI Oz1,A 019 :301,
�ppEXISTING ROOF COVERING
PHONE d S 3 — ( ` 3 ` NUMBER OF EXISTING COVERINGS
CONTRACTORS ,
n ((?( " !Sf
,Q,AC Q CY 2�e TO BE REMOVED TO BE RETAINED
NAME S
ADDRESS •2 �� C `,^ O� �'t— �(R COVERING
CITY&ZIP—J �' `dfA Vl J
l EXISTING
PHONE � — 1 (� (5 BUILT-UP ROOF ❑
LICENSE
ER Alo�^� H b Sd ASPHALT SHINGLES El
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, ^ - WOOD SHINGLES ElC
License Class _ 3`l Lip.Number Z 1 1 b S.1
Date I S Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION 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,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 violation Of
Code)or that he Is exempt antfora and the base for the applicant
to 7 SHINGLES 8"
exemption,civilpeltyofolt more than Section 7031.5 hundrbyanyapplicentfore permit subjects the applican�to
e civil,as owe not more then five hundred dollyeesre with
wage FWOOI'SHAKES ❑
❑I,as owner of the property,or to employees with wagee e3 their sole compensation,will s.
the work,and the structure Is not intended or offered for eels n owner
r4f Business and Proear
Ilona Code:The Contractor's License Lew does not apply to an ownere property who builds of WOOD SHINGLES ❑
Improves thereon,and who does such work himself or through ev own employees,Improvement provided that
Such Improvements are not completion,
the
offered for sale.ill however,the en building or Improvement
is notsold bull or
prove for purpose
sale.).Owner-builderwill have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose 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 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 Contractors License Law. 'PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
a Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: '•
❑1 have and will maintain a Certificate of Consent to self-Insure for Workers ComPenaaaon, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this p1 p
permit Is Issued. ( 99�' `/ Uo Seismic
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700p1 /
the Labor Code,for the performance of the work for which this permit is issued.My Workefb rY J
Compensation Insuref Ce carrier antl Po cy number era: p f LVN�H)INt) Total
Carrier 'S T; Fix PoncyNo.2g�yS—OCO�fy PERMIT AUTHORIZATIO IIAIKI
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be Completed If the permit 13 for one hundred dollars($1 W)or less.)
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 Ce16 All roof0 5 a I be inspected offUrTo an offing material being
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
subject 1.the Workers'Compensation provisions oftheOT CE TO APPLICANT: If,after makinthis Ci Lacate bor Code,of you musufo thwlithbecome comply Applicant understands and will comply with all non point
with such provisions or this permit shall 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 stale laws relating to building construction,and A—IL-mof coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes. g
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabllitles, ( '2
judgments,costs and expanses which may In any way accrue against said City In consequence SIGNATURE F APPLICANT DATE
of the 9r of this permit.
PRE-INSPECTION:
ION: 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