R-4993 PE
APPLICATION FOR CITY of cuPERTINo
NU e'ER R- 4993
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 MIT EXPIRES IF WORK IS NOT STARTED
WRITHIN 180 DAYS OF PERMIT ISSUANCE OR
. - 100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
Io1 / PNS CS e, RESIDENTIAL COMMERCIAL OTHER
OWNER'S e HAZARDOUS FIRE AREA
'
NAME YES ❑ If yes-I understand that a Class A
�f assembly is required.
� y NO Initial I.C.B.O.0
C/l
ADDRESS Y/Q /��'/Lam/^ EXISTING ROOF COVERING
PHONE — S VNUMBER OF EXISTING COVERINGS 00i
CONTRACT 'S
T TO BE REMOVED�TO BE RETAINED
NAME ,NYS- —�Gc
ADDRESS �1 k 1 p p TYPE OF ROOF COVERING
clry a zjP 93 �/"7Cs^ nr✓IL(><r (•/�• 64 EXISTING
Yob - 338-3 99 Joe(,
BUILT-UP ROOF ❑.
LICENSE L,6
NUMBER 7 / ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES
7000)of Division 3 of rho Business and Professions Coda,and my license Is In full force and
effect.
WOOD SHINGLES ElLicense Class ✓ _-3 Lic.Number 1_ _�xl,�/
Date 7 -
'� 96 ContrecOTHER(SPECIFY)
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 •0
applicant for such permit to file a Signed Statement that he Is licensed pursuant to the provisions
1 0l thesin ss and
License law(Chatter 0(commencing with Section 7000)of Division 3 of the
Business end violation
Coda)or that.he Is exempt therefrom and the oasis for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e clvll,penalty
as ow or not more than five hundred dollars with
wage
❑I,k, ownersthe cture is
Intended
or offered for
asectheir 7sole compessa lid Prlllt. WOOD SHAKES
the work,e: the structure is not Intended or offered for Bale(Sac.7044,Business end mods or
Ilona Code:The,and
who
License Lewdoes ielf or
hly to an roughhs own employers,who idedsor WOOD SHINGLES
Improves thereon,antl who tloen such work himself ar through his own employees,provided that
Such improvements are not completion,
leb n,or elleretl for seta.ill however,the building or improvement
Iso build
ornoneyearo purpose
sthe owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not builtl 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 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 Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt untler Sec. ,B&P.C.for this reason
owner Data APPLICATION DATE VALUATION PE I EE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
O I have and will maintain a Certificate of Consent to self-Insure for Workers Compensetlon, P`y i- Buildin
permit Is Is for by Section 37000lthe Labor Code,for the performance of the work for which this
permit Is Issued. C�(�`/C� r Seismic
r ❑ have and will the pelrf Worker's Compensation Insurance,as required by Section 370001 q
the pens Code,for the performance of the work for a which this permit is Issued,My Worker's O� 1 U Total
Compensation Insurance carrier and Policy number are:
N
Carrier Policy No. PERMIT'AUTHORIZATION DATE
v, CERTIFICATE OF EXEMPTION FROM WORKERS' rus
COMPENSATION INSURANCE IN C.I] V\
(This section need not be completed If the permit Is for one hundred dollars Si 00)or less.)
I certify that in the performance of the work for which this permit is issuedshell not employ
any person In any manner so as to become subject to the Workers'Co persatlon Laws of Cell. All roos shall be inspected prior to ny roofing material being
fornia. installed. If a roof is installed without first obtaining an
Dale F Z A I� Applkz inspection,I agree to remove all new materials for inspection.
subject
NOTICE the Workers'
ers'Compei,after nsation provisions oftrtificate
of he Labor Cod , ou must forthwithecome
comply omply Applicant understands and will comply with all non point
with such provisions or this permit ehalQbo 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 to class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for ler
epsilon purposes. �����
(We)agree to neva,Indemnity and keep harmless the City of Cupertino against liabilities,
judgments,gran costs and permit. s which may In any way accrue against said Clry In consequence
of the granting or this permit. SIGNATURE OF AP ANT DAT
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
li DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
_ OFFICE COPY _