R-4714 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER " 4 714
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
RESIDENTIAL COMMERCIAL OTHER
LOWNER'S HAZARDOUS FIRE AREA
YES D II yes-I underalaM that a Class A
NAME 7 /l mW asserr�y a required.
NO Initial I.C.B.O.Y
ADDRESS ( T .nST�L� EXISTING ROOF COVERING
PHONE _ NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
TO BE REMOVED / TO BE RETAINED
NAME
ADDRESS Q '7 1 TYPE OF ROOF COVERING
CITY&ZIP— L ` ,%`''//'VGO��
G EXISTING
PHONE Y7—�� Q G 14 7 BUILT-UP ROOF ❑
LICENSE
NUMBER /73 ASPHALTSHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby allirm that I am licensed under prmalons of Chapter B(commencing with Section WOOD SHAKES
]000)of DMsIxn 3 of me Business arM Professional Code,and my license Is In lull force and
aHsct. �/y/
License Gess — Uc.Number
S J 3 WOOD SHINGLES El
Date J— OTHER(SPECIFY) ElContrectw
OWNER-BUILDER DEC PROPOSED
hereby eHlrm they em exempt from the Contredore U Lew for me lolbvdrg reason.
(Sac.7031.5,Sinuous and Proleaalons Code: Any city un y which reci a permit to
constmcl,after,improve,demolish,or repair any structure, r tohslesuence,else requires the BUILT-UP ROOF P� a
applicant for such permit to file a signed 5latement met he is licensed pursuant to the prwfalons ,❑�
of the ss,and Pral Usines Lew,(Chapter 8(commenting arm Section]000)of for Me 3 of me t SDr
"emess end Professions Code)on met be Is exempt merehom am the baste he the alleged ASPHALT SHINGLEJy /f
a chh)pen.Artyf not onel9egbn]031.5byeery s($50 ).bra pemkt subjects the apWeanl to N
'e cMh penalty of rqi more Man five hundred dollen(5500).):
El 1,et owner of the property,or rtry employees with wages as their sole compensation,will do DSHAKES CI)Y(( �J
Me work,ark me structure Is not Intended or offered for cab(Sec.7044,Business entl Pmfes- F('��•[
alma Code:The Contractors Uconse Lew does not apply to an owner of property who bulks or OO SHINGLES Er•-/
Improves thereon,entl who does such work himself or through his own employees, nen provided that ❑��
such Improvements are not Imerked or offered for Bele.If,however,me building on Improver
Is Bold wtrhln one year of completlon,do owner-duller will he"the burdenodrg of prthat he m- ,�, OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,asownerolmeproperry,ammelu.Nelymntrectingwllhlc nsWwntmctostoconstrud-• -
the project(Sec.7w4,Business and Professions Code:The Contrtl Ucense Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who bustle or Improves thereon,and who contracts for such projects
won a contrsctor(s)Ilcensm pursuant to me Contractor.License law. PROVIDE MFGR.INSTALLATION SPECS.
-❑1 em exempt under Sac. ,B&P.C.for this reason
owner
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the fallpMng declaration:
-11 he"and will mainstem a Certificate of Consent to self-Insure for WoMer's Compensatlan, - BUIIdin
as provided for by Section 3700 of the labor Cotle,for the performance of me work for which mis
permlt Is Issued.
111 have and will maintain Worker's Compensation Insurance,as required by Semon 3700 of �� /y / L-// �OOD, Q V .Seismic
the Laborfor me dormence of the rk for which this permit is hall My Workere r/ /
Compenaa InCode,cur canis, toy holder are: Total
Carrier Pb,py.o/Q
kAC-363 !�QQ PERMIT AUTHORIZATION DATE
CERTIFICATE F EXEMPTION FROM WORKERS'
NSAT10N INSURANCE N.C.0
(This section need not be completed 8 the perm br one hundred dollars($100)on bas.)
I certify that In me performance of the work 1 t, hole penult fe Iewed, eh.11 not employ
any person In any manner w ns to become eu m e workers'compenaetlon laws of Call All roofs Sh I i pe rlor to any roofing material being
torrid, installed. If a roof is installed without first obtaining an
Data-� Auplham inspection,I agree to remove all new materials for inspection.
NOTI TO UCANT: II, ter"= hole Ce e o Examptlo ,you should become q I' t understands and WIII Comply with all non int
subject t the Worker'Compensation pro Wiens of a Lebon Code,you must forthwith comply PP P Y Po
with such pmdvloru or Me permh shall be deem eaokeof S rce r ulations.
I certify,mel l have read Me applkatlan arks that the above informed
is correct. agree \
to comply with all dry and county ordinances and state levo relating to building construction,and All o fob as roe r.
hereby eutlwnze representatives of rife city to enter upon me slue-mentioneis property foragree
In-
speckro purposes.
(We)agree to save,kdemolfy and keep harmlem me Cry of Cupt lrw against Ilebllhlea,
jutlpmenta,costs and expenses which may In airy way accrue against veld City In consequence
of Ilia granting of m1al pemmu. SIGNAT O APPLICANT PATE
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