R-4901 APPLICATION FOR clTv of cuPeRTINo
NUMBER R- 49
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 �j
11 ` RESIDENTIAL ' v COMMERCIAL OTHER
OWNER'S - HAZARDOUS FIRE AREA
1 f YES C] If yes-I understand that a Class A
NAME x+s�IP g V a,L t I roof assembly is required.
NO ]o Initial I.C.B.O.N
ADDRESS `%1W �g'.C�S i rpm ZC'a EXISTING ROOF COVERING
PHONE O — NUMBER OF EXISTING COVERINGS Z
CONTRACT r ^1/ J^'
6 Av= '�Do r i my TO BE REMOVED TO BE RETAINED
NAME
ADDRESS �+ �� S w 1 Sc , TYPE OF ROOF COVERING
- ( BSS Ja- - �
CITU BZIP - �.�II
PHI
EXISTING
PHONEI�f'I b/ ,�� y BUILT-UP ROOF ❑
LICENSE
NUMBER i;' ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with section WOOD SHAKES ❑
]000)of Division 3 of the Business and Professions Code,and my license Is In full force and
affect. WOOD SHINGLES
License Class
G` Lic.Num Z C> ❑
OTHER(SPECIFY) ❑
Date 7a, Con actor
OWNER-BU RD RATfoN PROPOSED
I hereby affirm that I am exempt from the Contrac is License aw for the following reason.
(Sec.7031.5,Business and Professions Cotle: Any r c y which requires a permit to
construct,alter,Improve,demolish,or repair any structure,prlorto its issuance,also requires the BUILT-UP ROOF I�
applicant for such permit to lila a signed statement that he Is licensed pursuant to the provisions
of the Contractors License Lew(Chapter a(commencing with Section 7000)of Division 3 of the
• Business and Professions Cotle)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($500).):
[:] WQOD 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 Proles"
alone Coda: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 through his own employees,provided that ❑
such Improvements are not Intended or offered for sale.If,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) ❑
not build or Improve for purpose Of sale.).
❑h as owner of the property,em exclusively contracting with licensed contractors to construct
the project(Sac.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 Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B 5 P.C.Mr this reason
nQ\ 1
Owner Aare AP.PLICATION`DATE' VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION .. ,. �.
I hereby affirm under penalty of perjury one of the following declaration: 7� `,-("f
-11 have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, Buildin
v �•�1�7I g ✓ 7
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this `` "�13Y1 (((___��^
permit layIssued.
yJ n 3�. Seismic
eve end will maintain Worker's Compensation Insurance,as recut red by Section 3700 of `` c Pw\
the ebor
Code,for the performance 01 the work for which this permit Is Issued.My Worker's G\��`v Q�F \w\O Total
Componsatlon lns1uranceLcerrlerLgOy Polic /numberere: ',�I / ``t
Carrier C 4TL-rt^hfV PollryNo.2L��-z, ��Fy Ci.�t �PE�FIMI1� UTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' B
COMPENSATION INSURANCE N.C.❑ _�� ij
(This section need not be completed if the permit Is for one hundred dollars SI 00)or Iess.) 7
I certify that In the performance of the work for which this permit Is Issued,I shall not employ
any parson In any manner so as to become dllaet4a4p�wmaera'company Ion Lawy of cell- All roof^shall be inspected prior to any roofing material being
forma. installed. If a roof is installed without first obtaining an
Data App Tont inspection,I agree to remove all new materials for inspection.
subject IOEhe Workers'Competo APPIACANT: nsaaft0on provislonr inis fetes 11Lee,Code yolu mustulorthwlthbecome Amply Applicant understands and will comply with all non point
with such provisions or this permit shallfbe stable yoked. source regulations.
I certify that I have read this application and state that a above Information Is correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,antl All s to b lass" "or better,
hereby authorize representatives of this city to enter upon the above-mentionetl property for Ira
spection purposes.
(We)agree to save,indemnity and keep harmless the City of Cupertino against Ilabilities.
judgments,costa and expenses which may in any way accrue against said City in consequence U PP ANT AT
of the granting Of this permit.
PRE-INSPECTION: PLYWOOD: ROGRESS:
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