R-4889 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R— 48 H 9
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
• _
WITHIN 1B0 DAYS OF PERMIT ISSUANCE OR
WI180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
�3 L )wy44-0
Q
r/ RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
T/ ES E] II yes—I understand that a Class A
NAME 'T , mol assembly is required.
/ �/ til./ / /L(�./ NO Initial I.C.B.O.k
ADDRESS
S EXISTING ROOF COVERING
PHONE C;�5__'2_ / NUMBER OF EXISTING COVERINGS
CONTRACTOR'S Ji -
TO BE REMOVED TO BE RETAINED
NAME 7
ADDRESS 6 W'I /'� '0 �p / / /C �f nln_� TYPE OF ROOF COVERING
CITY&ZIP
P "?, 50 o EXISTING
PHONE �+9- �3 � Q BUILT-UP ROOFLICENSE
❑
NUMBERASPHALTSHINGLES ❑ �%
LIC N D CONTRACTORS DECLARATION ❑ �r P
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license is in full force and
effect.
WOOD SHINGLES
License Class Lic.Number
a
Date Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from 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 PAI
.� Elapplicant for such permit to file a signed statement that he Is licensed pursuant to the provisions tl� A ��
of the Contractor's License Law(Chapter 9(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 SHINGLE
Ft
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to /�
e civil penalty of not more than five hundred dollars($500).): Am
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES 3C'D
the work,and the structure is not intended or offered for sale(Sec.7044,Business and Profes-
sions Code:The Contractor's License Lew does not apply to an owner of property who builds or WOOD SHINGLES/rY(Jf UF'
C
Improves thereon,and who does such work himself or through his own employees,provided that E(� T
Is
such Improvements are not intended or offered for sale.ill however,the enbuildingr or improvement
iem
n sold tbuild or
prove for purpose
sthe owner-builder will have the burden of proving that he Oitl OTHER (SPECIFY) Cp�'1`�
not build as
improve far purpose of sale.).
❑I,ec owner of the property,am exclusively contracting Coe:T with Contractor's
otl contractors to construct
the apply to
owner of property
who
and Professions improv Code:The Contractor's License Law does not PROVIDE LC.B.O.REPORT NO.
apply tc contractor(s)
owner of property whouant t or improves thereon,and who contracts for such projects
with aconiexempt neer Se pursuant to me Contractor's license Lew. PROVIDE MFGR.INSTALLATION SPECS.
I em exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION TE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby and ill under penalty 01 penury one of the following declaration: t
❑ have and willmaintaina of the
abof Consent toeperInsurefor workewo Compensation, Building I
as provided for M Section 3700 of fhe Labor Code,for the performance of the work for which this
permit' 'sued. � I
,�'h a antl will maintain Worker's Compensation Insurance,as required by Section 3700 of V - / y Seismic
the Ipbi Code,for the performance of the work for which this permit is issued.My Worker's
ComEEEensata� crand7tnumbar are: Total
Carrier LM�
Policy No. 6176527_7(4 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0 Z
(This section need not be completed it the permit is for one hundred dollars($100)or less.) l
I certify that in the perform nca 01 the work for which this p mit Is i'sued 1 shell no mploy
any person in a manners s m becrome subject 1 W re'Compensation Le ' 1 all.
All roof::shall be inspected prior to any roofing material being
fornla. ,^( installed. If a roof is installed without first obtaining an
Date `�_� Applicant inspection,I agree to remove all new materials for inspection.
NOTICE APPLIC T: If,after making this un to 0f Exemption,y u sh Id becom Applicant understands and will comply with all non point
subject to the workers'Compensation provisions of the Labor Code,you mu to wIU com PP P Y P
with such provisions or this permit shalrbe deemed revoked. source regulations.
I certify that I have read this application and state that the above information is correctI agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof covering o be clas °� Mr/b
hereby authorize representatives of this city to enter upon the above-mentioned property for In. 073
spection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may in any way accrue against said Ci ry in consequence SIGNATURE F APPLICA DAT
of the granting of this permit.
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