R-4507•
OFFICE COPY
PERMIT R_ 450 7
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
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS '
75
RESIDENTIAL Nii COMMERCIAL OTHER
O NER'S
HAZARDOUS FIRE AREA
y— /
YES E] If yes - I understand that a Class A
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NAME E) 10-
mol' assembly is required.
NO Initial I.C.B.O, a
c 4
ADDRESS aQQ-2J 0G /T/� n z/i vim_ G' r"
EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS rLt,
PHONE OSS
CONTRACTO
�%
Rci /1
/ �C� ��
TO BE REMOVED TO BE RETAINED
IliR'S
Ckr Cs �
NAME//
'F"'il��
TYPE OF ROOF COVERING
ADDRESS �1_ Q
�ke-Aw
3O /�G c]R.y Qe 25
`
CITY SZIP ,-7
EXISTING
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Q7/
PHONE 7S!5-5
_-BUILT-UP ROOF ❑
LICENSE
NUMBER
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 0 (commencing with Section
WOOD SHAKES �zJ
7000) of Division 3 of the Business and Professions Code, and my license Is In full force and
effect.
License Class � Up. Number J �6X;` t
WOOD SHINGLES ❑
OTHER (SPECIFY) ❑
8— 8__9S ROMAT
Date oontracl.,AW-SeaSVACS C.
OWNER BUILDER DECLARATION
PROPOSED
I hereby affirm that I am exempt tram 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, alter. Improve, demolish, or repair any structure, prior to Its Issuance, also requires the
BUILT-UP ROOF ❑
appicam for such permit to file a signed statement that he is licensed pursuant to the provisions
of the Contractorb License Law (Chapter a (commencing with Section 7000) of Division 3 of 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 more than five hundred dollars (8500).1:
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 Contractors License Law does not apply to an Owner of property who builds or
WOOD SHINGLES ❑
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 -builder will have the burden of proving that he did
OTHER (SPECIFY) ® MAX', � t-•
MAX',
not build or Improve for purpose of sale.).
I] 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 Contractor's License Law.
PROVIDE MFGR. INSTALLATION SPECS.
❑ 1 am exempt under Sec. .B 8 P. C. for this reason
Owner Date
APPLICATION DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
/r'1
I her affirm under penalty of perjury one of the fallowing declaration:
have and will maintain a Certlticete of Consent to sell -insure for Worker's Compensation,
BUlldln l/
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
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Seismic�'-tL
❑ 1 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
Total
Compensation Insurance carrier and number
411n I�
///Po��-lpicy� �are��:
Carrled�ry(Q,�Fk<y No.-?Jlbb38 -
QI PERM A
.ORIZATION
DATE
CERTIFICAT OF EXEMPTION FROM WORKERS'f.
COMPENSATION INSURANCE N.C.I]
(This section need not be completed If the permit Is or one hundred dollars ($100) or less.)
h%
J
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 Cali-
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 TO come
tlLabor
os youmustfothwithcomply
Applicant understands and will comply with all non point
subject othe Workars'Compensatlonpenv;si atthe Code,
with such provisions or this permit shale be deemed revoked.
Source regulations.
I certify that I have read this application and state that the above Information Is correct. I agree
"C" better.
to comply with all city and county ordinances and state laws rotating to building construction, and
All roof c en Class or
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes.
(We) agree to save, indemnity and keep harmless the City of Cupertino against liabilities,
(-J
judgments, costs and expenses which may In any way accrue against said Cityin consequence
T�'[T��
OF APPLICANT DATE
of the granting of this permit.
Jlurvnl"VRI!
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