R-4539 APPLICATION FOR CITY OF CUPERTINO
NUMBER PERMIT
R" 4539
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
/0368 cc �6r .9LF
RESIDENTIAL x COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
- YES ❑ If yes-I understand that a Class A
NAME S I7IFIZ I-/A r/ W D{}yl'.S roof wwmby Is required.
N Initial I.C.B.O.p
ADDRESS—/0340 C c "i A vc-7 EXISTING ROOF COVERING
PHONE 24�& ZS -6 V2 0 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
TO BE REMOVED_ TO BE RETAINED
NAME
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP
EXISTING
PHONE BUILT-UP ROOFLICENSE
❑
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am 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' WOOD SHINGLES ❑
License Class Lid,Number
Date Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,after,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 O(commencing with Section 7000)of Olvislon 3 of the
Business and Professions Code)or that he Is exempt therefrom and the basis far the alleged ASPHALT SHINGLES ❑
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
f
alryofnot mare roan five hundreddollars($500) WOOD SHAKES
owner ofthepropertyormyempoyeeswith wages as theirsoleCohnpenaetlon,will tloantl the structureisnot intended or offered forsale(Sec7044,Business antl Pmfes-
e:TheContractorsLicense Lawdes not applytoan ownerofpropertywho builds or WOOD SHINGLESthereonand whodoe.such work himselrthrough hisown employeesprovided that
ovements ere not intended or offered lar cele.II,however,the building or Improvement
Is sold within one year of completlon,the owner-builder will have the burden of proving that he did OTHER (SPECIFY) ❑
not build or Improve for purpose of sale.).
❑1,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 contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR. INSTALLATION SPECS.
1 am exempt under Sec. .B&P.C.for this reason
Owner Date APPLICgTION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION c.
I hereby affirm under penalty of perjury one of(no following declaration: ° 1
0I have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, BUlldln
as provided for by Sectlon 3700 of the Labor Code,for the performance of the work for which thisVO
permit is issued. AU6 23 199 ' Z— 0 Seismic
C]I have and 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 Worker's C)lY Total
Compensation Insurance carrier and Policy number are: Uf" Lilt'(-
Carrier Policy No. PERMITAUTHORIZATIO DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed If the permit Is for one hundred dollars($100)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 Cell. All roof^shall be inspected prior to any roofing 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.
NOTICE Olafter
atlsthis
tflcate ruushould
bCcame
subject to the Workers'Compenoprroviions ofheLabor Code,you mstfothwithomply Applicant understands and will comply with all non point
with such provisions or this permit shalt;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 class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
sp(Wiff purposes. 9( 2 /4_5
(We)agree to save.indemnify and keep harmless the City of Cupertino against liabilities, s••�__I- I ,fJ � r/ 3 7 J
judgments,costs and expenses which may In any way accrue against said City In consequence SIGNATURE
F APPLICANT DAT
of the granting at this permit.
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