R 4683 PERMIT R_ 4683
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
WI180 DANS FROM LAST CALLED INSPECTION.
BUdo
/ �
BUILDING ADDRESS �-Q
V ry v`-' r - — RESIDENTIAL COMMERCIAL OTHER
OWNER'S �` _ HAZARDOUSF RE
NAME CL ( �"'6f��""— NES ❑ If yes-assI at a Class A
roof emblymbly is required.
Ih
NO 1:1Initial I.C.B.O.8
ADDRESS SO_ ' %_C EXISTING ROOF COVERING
PHONE I "f �P NUMBER OF EXISTING COVERINGS /
CONTR
TO BE REMOVED TO BE RETAINED ` 1
NAM
ADDRESS TYPE OF ROOF COVERING
' CITYB ZIP `- I
PHONE L.0 S r �l BUILT-UP ROOF
LICENSE Z ASPHALT SHINGLES
NUMBER ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is in full force and
effect.
Rr WOOD SHINGLES ❑
License of ^�' Lid.Number ` ,GLJ-1J,�- r- OTHER(SPECIFY) P A
tP
Da te1 ( 1 L..A.L�Cohn
-BUIUaor
rm `` _``eOWNER-BUILDER DE A PROPOSED
here ffirm that am exempt from me e: Anytcity License Lew for the linofoaminga preason. 9 1906
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to 'Fill
� v lOOl7
construct,alter,Improve,demto file signed statement that
prior JoIts Issuance,also requires the BUILT-UP ROOF �-pl�
et the Co for such permittolila asignedr 9(co nl that he it licensed 7000)of Loins provisionsothCIT`! OF CUI Er IIfvU
dp of the Contractor's License Low(Chapter B([a amci with Section 7000)of Division 3 0l the ll PCr{I
Business and Professions Code)or that he is exempt h felfom and the basis for the alleged ASPHALT SHINGLES 13exemption.Any violation of Section 7031.5 by any appli lot permit 8blects the applicant to
e civil penalty of not more than five hu re do rs($50 )
❑I,as owner of the property,or m mploya wI their sale compensation,will do WOOD SHAKES ❑
the work,entl the structure is no entled or off pl ec.7044,Business and Profes.
alone Code:The Contractor's nL .se Lew r to an owner of property who builds or WOOD SHINGLES
improves thereon,entl who d(1E such I . rough his own employees,provided that ❑
such Improvements ere not In11pp ad r r I,. at .If,however,the building or Improvement
is sold within one year of comple' the wner.bullder will have the burden of proving that he did OTHERSPECIFY
not build or Improve tar purpose of :1' OTHER(SPECIFY) ❑
❑I,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for Such projects
with a contractor(s)licensed pursuant to the Contractors License Lew. PROVIDE MFGR.INSTALLATION SPEC$.
❑1 am exempt under Sec. ,B 8 P.C.for this reason r
Owner Dale
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and w111 maintain a Certificate of Consent to self-Insure for Worker's Compensation,
as provided for by Section 3700 o1 the Labor Coda,for the performance of the work for which this BUllding S
1 (Cq
�� �
--Seismic permit Is Issued. I[)I have entl will maintain Worker's Compensetlon Insurance,as required by Sactlon 3]00 of
„the Cotle,for the performance of tine rk for which this permit Is Issued.My Works a
:0 ons 11 n Insur no
carr nd Policy mb t Total
c b` g No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF XEMPTION FRO WORKERS'
COMPENSATION INSURANCE N.C.❑ r
(This section need not be completed II the permit Is for one hundred dollars($100)or lase.) I
I certify that In the performance of the work for which this permit Is Issued, shell not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Cell- All fOOfF sin II be inspected prior to a y roof' Ig material being
torula. 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,you should become
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shal0be 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 ala "C"or better
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes.
(Wel agree to save,Indemnify and keep harmless the City of Cupertino stgamst Ilabllitios,
. of the g granting of this permit as which may In any way accrue against said City In consequence ATURE OF APPLICANT DAl
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