R-4719 APPLICATION FOR CITY OF CUPERTINO
NUMBER PERMIT
R- 4 719
INSPECTION DIVISION PERMIT EXPIRATION
REROOFPERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 160 DAYS OF PERMIT ISSUANCE OR
160 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
10210 N. Foothill Blvd . , Cupertino
RESIDENTIAL x COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
Mr. Gary Johnson, J. Cyril Johnson Inv YES ❑ Ityes—lunderstandthata ClassA
NAMEGerp. roof assembly is required.
NO Initial I.C.B.O.q
ADDRESS 125 Willow Road, Menlo Park EXISTING ROOF COVERING
PHONE 415-324-9021 NUMBER OF EXIST`
CONTRACTOR'S
NAME Shaughnessy Roofing, Inc. TO BE REMOVED TO BE RETAINED
-'� ADDRESS YYPEOFROOF COVERING
CITY&ZIP P. 0. Box 5705 , S. S. F. , 94083
EXISTING
PHONE 415-992-3255 BUILT-UP ROOF
LICENSE
NUMBER #410394 ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
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 farce and
affect.
License Class C-39 Uc.Number #410394 WOOD SHINGLES El
Shaughnessy in /
Date UB/31./97 Contractor Shau 9 y Roof9 OTHERSPECIFY(SPECIFY)
OWNER-BUILDER DECLARATION P OSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason. b
(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 Ul
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions UP ROOF n^
of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the. J`,
Business and Professions Coda)orthat he is exempt therefrom and the basis for the alleged A ALT SHINGLES C
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than live hundred dollars($501 WOOHAKES (,/-
❑I,as owner of the property,or my employees with wages as their sole compensation,will do r40
the work,and the structure is not intended or offered for sale(Sec.7044,Business and Profes-
sions Code:The Contractor's License Low does not apply to an owner of property who bunds or WOOD SHINGLES ❑ �ryyl'(J
Improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not intended or offered for sale.it,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.).
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 net PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who bullds or improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contracture 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
y WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, Building as provided for by Section 3700 of the Labor Code,for the performance of the work for which this 04/09/96 $12 ,000. 00
permit is Issued' Seismic 1 - 9
,0p1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
bill
bor Code,for the performance of the work for which this permit Is issued.My Worker's
Compensation Insurance carrier and Policy number are: Total
Cand,rReDublic Indemnity PolicyNe, PC3908575 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.[]
(This section need not be completed If the permit Is for one hundred dollars($100)or less.)
I certify that In the performance of the work for which this permit Is Issued,I shall not employ
any person in any manner so as to become subject to the Workers'Compensation Laws of Cali- All r0 II be Wspected prior to any 11,oofin aterb ' g
fornix. installed. If a roof is installed without fir obtaining an
Data 04/09/96 Applicant Shaughnessy Roofing inspection,Iagreetoremoveallnewmateri Is for inspection.
NOTICE TO APPLICANT: It,after making this Certificate of Exemption,you should become Applicant understands and will I with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pp comply y P
with such provisions or this permit shapbe 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,antl All fcover ngs to be lass„C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spenion purposes. 04/09/96
(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 City in consequence T DATE
of the granting of this permit.
PRE-INSPECTION: PLYWOOD: V IN-P GRESS:
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
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