R 4913 PERMIT R_ 4 913
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN DAYS PERMIT ISSUANCE OR
WI DAYSS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
I O Z 9 4 S. I , e4ij 1 q
V RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
I VES ❑ If yea—1 understand that a Class A
`
NAME v e Y roof assembly Is required.
//��^^��MNO Initial I.C.B.O.A
ADDRESS
L ` I CL Vt EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS I
CONTRACTOR'S \'�/OC J
NAME i fill ` iNGL TO BE REMOVED TO BE RETAINED
ADDRESS �+ TYPE OF ROOF COVERING
CITY B ZIP I �7 S .�t c Jo . 7
If Z EXISTING
PHONL�''f btb) 97_1 -7 60 n BUILT-UP ROOF � J
LICENSE -ell{- E]
NUMBER y!ti(,e. �Z b / ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION ❑
I hereby affirm that I am Ilcensed 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 lull force and
effect.
c WOOD SHINGLES
License Cleas C — 1 Lie.Numbs
Date contra OTHER(SPECIFY) n'❑ ' 9
OWNER-BUILDER DEC N PROPOSED ��/V b'
hereby affirm that I em exempt from the
Comma
is nee Lew for the following reason. _ 1n
(Sec.7031.5,Business and Professions Code: An or county which requires a permit to 9
construct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF 9
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 Dlvlslon 3 at the
Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES ❑
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not mora than five hundred dollars($500).): WOOD SHAKES
[:]I,as owner of the property,or my employees with wages as their sole compensation,will do ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes-
sionsCode:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work himself or th rough his own employees,provided that ❑
such Improvements are not Intended or offered for Safe.If,however,the building or Improvement
is sold within one year of completion,the owner-builder will have the burden of proving that he didOTHER(SPECIFY) Elnot 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 bullds 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 9 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one or the following declaration: l-
❑I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, Building
as provided for by Section 3700 of the Labor Code•for the performance of the work for which this
s permit Is Issued, / Seismic �
❑ have and will maintain Workerperformance
Compensation the work
for Insurance,as required Is i su Section Worker's's O
the Labor Code,for the potormance of the work for which this permit le issued.My Worker's
'Compensation Irm fe/nce ce/rrler antl�!lcc-y number are: / Total
Carrier 'CuY 2 F L.w d Polley No. Z/7 S PERMIT AUTHORIZATION DATE
CERTIFICATE EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N /y
(TMs section need not be completed II the permit Is for one hundred dollars($100)00)or leas.) Yl.
I certify that In the performance of the work f Is Issued,I shall not employ
any person In any manner So as to beco act e W om ens Ion Lews of Celb All roots sh a inspected prior to any roofing material being
°rola' installed. If a roof is installed without first obtaining an
Data b L Ap inspection,I agree to remove all new materials for inspection.
subject to them ereCComp°nsation proviafter sions of t Labareor Code.of you mustuforthwith 0ecome comply
Applicant u ds and will comply with all non point
with such provisions or this permit shellibe dee oketl. SO egulations
I certify that I have read this application and state that the above information It correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,antl All roof oval acla or after.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes. 6 Q
(We)agree to save,Indemnity and keep harmless the City of Cupertino against Ilablll s,
judgments,costs and expenses which may In any way accrue against said City In consequ ca
of the granting of this permit. SI F APPLICANT ATE
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 I