R-4580 PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 4580
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
&V9 S //, ve 41,104 l�✓.
RESIDENTIAL COMMERCIAL OTHER
OWNER'S / HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a ClawA
NAME �Gd ( �(� root assembly is required.
Ni - Initial I.C.B.O.If
ADDRESS EXISTING ROOF COVERING
PHONE 6Y'(J b/ NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
V7 ,./� /' v6L/ l �D TO BE REMOVED TO BE RETAINED
NAME__L(—CJVf_ V Gr
ADDRESS •7U�l ND rfy✓U� s S , TY
CITY 8 ZIP V FRO COVERING
EXISTING
PHON(4-a e")- -Z 95 _ 9 S 9 BUILT-UP ROOF
LICENSE
NUMBER ASPHALT SHINGLES El
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provislons of Chapter B(commencing with Section WOOD SHAKES Cl
7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and
effect. /
t 8, WOOD SHINGLES ❑
License C ass S Lic.Number s�o L
Date 9 contractor tjroG' OTHER(SPECIFY) - ❑
ir OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Lew for the following reason.
(Sec.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 pw P�D
applicant for such permit to fila a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Law(Chapter a(commencing with Section 7000)of Division 3 of the
Business and Professions Coda)Or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGL;J
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to I
a civil penalty of not more than five hundred dollars($50l
EJ 1.as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES L(/N�h ❑
the work,and the structure Is not Intended or offered for sale Sec.7044,Business and Profes.
stone C0 do:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES 7
Improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not intended or offered for sale.II,however,the building or Improvement
Is sold within one year of completion,the owner-Wilder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Cade: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 contractors)licensed pursuant to the Contractor's License Law. - PROVIDE MFGR.INSTALLATION SPECS.
[II em exempt under Sec. ,B 8 P.C.for this reason
Owner oats
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
-11 have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, BUIIding
permit Is for by Section 3700 of the Labor Code,for the performance of the work for which this O
permit ie edforIssued. ' V
${I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of Seismic
the LHbar Code,for the performance of the work for which this permit Is Issued.My Worker's 4
Compensation�Insurance carrier and
Policy number are: Total
Carrier 5l�r� Yarl Policy No. G21-94— PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE N.C.p
(This section need not be completed it the permit Is for one hundred dollars($100)or less.) FDP I
I certify that In the performance of the work for which this permit is issued,1 shall not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Cell- All roots shaffi bellinspected prior to any roofin material being
forma. installed. If a roof is installed without first obtaining an
Date 9/!� Applicant /?r1D f 6 4tW �O inspection,I agree to remove all new materials for inspection.
Nott TO Prs'Compensation
o :p nsati npeking this visionsofth Late bor Code,youmustuforthwlthbecome
comply Applicant understands and will comply with all non point
subject to the Workers'Com e,after provisions of the Labor Code,
with such provisions or this permit shall 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 ro ICO rings to be cls C°Or better.
hereby authorize representatives of this city to anter upon the above-mentioned property for In.
spection purposes. /
(We)agree to save,Indemnity and keep harmless the City of Cupertino againstliabilities,
• judgments,costs and expenses which may In any way accrue against said City In consequence
of the granting of this permit. NATURE OF APPLICANT 4ATE
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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY