R-4612 PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 4 612
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT 777.322$ PERMIT EXPIRES IF WORKIS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
COMMERCIAL OTHER
Ow R' HAZARDOUS FIRE AREA
N E L/ / °y 'U I�/ , YES ❑ It yes-I assembly
i req that a Class A
roof assembly is rand that.
�� L �� NO ROOF
I.C.B.O.q
ADDR Q1�/,// EXISTING ROOF COVERING
PHONE -73?- � O ( NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S ^ y
,V` xx �'nc/! TO BE REMOVED TO BE RETAINED
NAME
ADDRESS ,C/�W /f ��� TYPE OF ROOF C,QVERING
CITY&ZIP /lam
L� ¢�]] EXISTING
PHONE% D/� 371'7- 8'77?U ` ! ? BUILT-UP ROOF ❑
NUCENSEMBER lU J 3,_'a� 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 lull force and
effect.
///��\/ WOOD SHINGLES ❑
License Class —� Lic.Number`-'�� `-'
AW
Dale S Contractor t OTHER(SPECIFY) ❑
OWNER-BUILDER D CLA TION 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 ❑
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions
. of the Contractor's License Lew(Chapter 9(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
e civil penalty of not more than five hundred dollars($501 WOOD SHAKES ❑
C]1,as owner of the property,or my employees with wages as their solo Compensation,will do
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profes.
Bions Code:The Contractor's license Law does not apply to an owner of property who builds or WOOD SHINGLES
❑
Improves thereon,and who dealt 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.).
❑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 Lew 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 Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B It P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT F
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: P n n /n�
❑I have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, W 6 yl, Buildin
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. n Seismic
�ihove and will maintain Worker's Compensation Insurance,as required by Section 3700 of Er 2719
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's 95 6�-�(,� Total
Compensetiq Ins rents erne nd Policy number are: /lJT3,
Carrier Policy No./L '/w LiPERMITJAUTHQ9,IZJnN 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 Call- All roots 9hall be inspect4J prior to afiy rodfing material being
tornia. installed. If a roof is installed without first obtaining an
Dale Applicant inspection,I agree to remove all new materials for inspection.
NOTsubject llo the WCE TO orkers'Compensation It,after provisions al theicate of Laborr Code,you mustforthwiou thbecome
Comply Applicant understands and will comply with all non point
with such provisions or this permit shall be 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 Allroof ova sto be class
°q��.S
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes.
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may In any way accrue against sold City in consequence 91`9❑VA RE OF APPLICANT DATE
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