R 4791 PERMIT R_ 4791
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
•
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
WI-180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS -{n�.�nY� • �x,
f (".J, RESIDENTIAL �x COMMERCIAL—OTHER—
OWNER'S
OMMERCIAL OTHEROWNER'S HAZARDOUS FIRE AREA
VES ❑ If yes I understand that a Class A
NAME roof assembly is required,
��I _ NO Initial LC.B.O.N
ADDRESS (� ^F lI, n EXISTING ROOF COVERING
PHONE L4 O O �` le " _ ^ b 1 NUMBER OF EXISTING COVERINGS cx_�
CONTRACTO 'S
TO BE REMOVED TO BE RETAINED
NAME
ZYPE OF ROOF COVERING
aTvazlP (,
b D 3� i - a,5 o Y (. ► " , qSo EXISTING
PHONE \
BUILT-UP ROOF �
LICENSEL /,
NUMBER V� ASPHALTSHINGLES
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES ❑ 9�
7000)of Division 3 of the Business and Professions Code,and my license is In full force and a g�
effect. j.( WOOD SHINGLES p❑/,.r
License Class Lic.Number � IN
Dale Cant, for �7 - OTHER(SPECIFY) IVI�R 1 M96
IL OWNER-BUILDER DECLARATION COy `+�
I hereby affirm that I am exempt from the Contractors License Law for the following reason. PROPOSED UI• U00 1:pf I ffV
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to V
construct,after,Improve,demolish,or repair any structure,prior to its Issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
• of the Contractor's License Law(Chapter B(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 SHINGLES �W11
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).):
01,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profes-
sions Code:The Contractors 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 emplcyeea,provided that ❑
such improvements are not Intended or offered for eels.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.).
❑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 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 contractors)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS,
❑1 am exempt under Sec. ,B B P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION '
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and y Ill maintain a Certificate of Consent to self-insure for Workers Compensation, J V Building
as provided for b Section 3700 of the Labor Code,for the performance of the work for which this
permit IsIssued.
and. a a 0 SelsmIC
❑ have and will the performance
rmacWorker's Compensation Insurance,as required Is I by Section 3700's 2��R
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's 1 y Total
- 4;—
Co pensetlon In'sy'�le�nQ��cerrie'`�d Policy nurbar ere: q d
Carr r sz4vc 1 (/V�1�' policyNo.�y�7 I 1 -I S C'1r r Uh PERMI T TION T
CERTIFICATE OF E%EMPTION FROM WORKERS'
COMPENSATION INSURANCE 100)0 Y
(Thle section naetl not be completed If the permit is for one huntlretl dollars($100) Ir 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 eo ae to become sublact to the Workers'Compensation Laws of Cell- All rootsshall be inspected prior to any roofing material being
rornIs installed. If a roof is installed without first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
NOT subject toEtheOWorrkam'Compefnse on provisi this
of thlelcate of Laborr Code,you mustuforthwlitlbecome
h comply Applicant understands and will comply with all non point
with such provisions or this permit shalpbe 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 be cl SS"C"O better.
hereby authorize representatives of this city to enter upon the above-menlloned property for In-
spection purposes. 1 3
jWe)agree to save,indemnify and keep harmless the City or Cupertino against Ilabi111ies,
• judgments,costs and expenses which may In any way accrue against said City In consequence
of the granting of this permit. SIGNATURE O APPLICANT ATE
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