R-4844 PERMIT '
APPLICATION FOR CITY of CUPERTINO NUMBER R- 4 844
INSPECTION DIVISION PERMIT EXPIRATin,
REROOF PERMIT (408)]7]-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
BUILDING ADDRESS 180 DAYS FROM LAST CALLED INSPECTION.
6SIDENTIAL COMMERCIAL OTHER
OWN R'S ` - HAZAR
C VES E] IF -I understarld that a Class A
NAME 1\�lS� roof assemhly,is required. _
_ - NO , Initlal I.C.B.O.p
ADDRESS
19 3 k S �—�rJQ e,� � If EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTR_'�TL(�,J;TOR'S xy(7,� C -
NAME c CA.rQ[!A L S�--• dCT L nn4 TO BE REMOVED TO BE RETAINED
ADDRESS�' �v� �1 S L?. CA TYPE OF ROOF COVERING
CITY 8 ZIP /� - /
!/ EXISTING
PHONE 'S yy s/ BUILT-UP ROOFUCENSE
❑
NUMBER 7. Z— ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby whirrs that I em licensed under provlelone of Chapter B(commencing with Section WOOD SHAKES
]000)of Division 3 of the Business and Prolesi lons Code,and my license Is In full force and S/
effect. /b
Z WOOD SHINGLES ❑
Ucense Claes ' �� Dc.Number S
Date �1 Z Contractor �� l t o� OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors License Lew fw the following reason.
(Sec.7031.5,Business and Profession 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 ❑
epplbant for such permit to IIM a agned statement that he is licensed pursuant to Ne proAsiwo
of the Contractors License Law(Chapter a(commandrg 44th Section 7000)of ONsIon 3 of the
Business and Professions Code)or that he Is exempt tlrerefrom and the basis for the wagetl ASPHALT SHINGLES ❑
exemption.Any vblatlon of Section 7031.5 by wry applicant for a permit subjects the applicant to
e tivil,as lty
of rot more then live bundredy employees
coloyees y(5500)e
❑I,k,and!
er Me f thecwhe is net I tended vyeeered for Is as Molr sole compensation.sand
Pr ll do WOOD SHAKES
the work,a+htl Me structure Ie net Intended ores not for eels(Sac.Owner
Of Business end Proles-
ebnsCode: The,ak!who d License Lew doesnot apply toan hhowner enproperty w1,0buildsw WOOD SHINGLES
suchImprovesImp thereon,enol who does such coo offered
forhimself or through his awn empbyeea,provltlatl that
such I vwfo n rtie year
we rhor Intended M offeretl b isale.If,however,Ma building r c,I g Mat
is sold cod or
prove Xelcempletof s Me owror-bWltlerwill have the Wrden of proving that hs,tiff OTHER(SPECIFY)
'
net WIW or Improve bw purpose of sale.). ❑
❑I,as owner of the property,em exclusively contracting 44th Ibensed contractors,to construct
the project(Sec.7044,Business entl Prof hsoone Code:The Contractors License Lew tloen not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who Wilds or Improves thereon,and who contracts for such protects
with a contmctw(a)licensed pursuant to the Contractors titans Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,S 8 P.C.lar this reams
Owner Data APPLICATION,DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION .�
I hereby affirm under penalty of perjury one of the IolloMrhg tlecleration:
pl have and*111 maintain a Cert fkats of Consent to soft-insure for Workers Compensation, APA n� Building •
as provided for by Section 3700 of the Labor Coca,tar the performance of the work for wlJch this !{ y( n
>r-tt Is leeued. y 9G SelSmlc It O
/.P7lihave entl will maintain Wck*ws Companaetlon Insumutce,as required by Section 3700 of CII y Ur
e Labor Code,for Me performance of the work far which this permit Is issued.My Workers L
Compenmaflart Insuiw cerrlp,aLd NBq number aro: � Lrt1T I hl��C"� Total
Csnbr �"�+`\I�- (/J3 rolicyNc. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FRAM WORKERS'
COMPENSATION INSURANCE N.CQ J\...
(This section now not be compared II the permit le Iw one hundred dollars(2100)w lees.)
I certify that In the performance of Me work for which this Permit is Issued,I s of employ
any person In any manner so as to become subject to the Worke 'Comics If of Cali- All roofs shall be inspected prlocto any rooting material being
fwrla' C installed. It a roof is installed without-first obtaining an
Date "�: / Applicant Inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: IL after making this Certificate of Exemption,you should become Applicant understands and will comply with all non rot
subject to the Workers'Compensation pro0slons of the Labor Coce,you must forthwith cornpty PP p y p0
with such provbions or MIs pentyl shall be deemed revoked. source regulations.
I cenity that I hoe reed this applkatlan and state that the above Information Is correct.I agree
tecomply uthorzldryastl county wdhsncm entlstateteru In the relating h<wa-mentioned!
for In. All roof ver be class"C" 9tter.
hereby euurpo a representatives of this dry to enter upon the above-mentioned property for In \\\ '
epectlon purposes. \ K
(We)ogee to save,Indemnify and keep harmless the City of Cupertino against lablues, y4e
ju sante,coots and expenses which may In any way accrue against said Gry In conaequaroe
eof granting of this Permit SIGNATURE OFAPPLICANT DATE
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