R-4620 PERMIT R_ 4620
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
• 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
aaos 1 NJ bIscus
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
C hr�s Orr' YES C-] If yes—IunderstandthataClassA
NAME root assembly Is required.
NO Initial I.C.B.O.W
ADDRESS 4o5I Hr b+SGJ_S pr EXISTING ROOF COVERING
PHONE 7-3 I _ 67-77 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S o� p
NAME
Dsee dJ a Regfi f TO BE REMOVED 70 BE RETAINED
ADDRESS TYPE OF ROOF COVERING
CITY s ZIP EXISTING
PHONE BUILT-UP ROOF ❑
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 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 Cless Lic.Number
Dale 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 ❑
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions
• 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 SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to Ix
a civil penalty of not more than five hundred dollars($500).1: WOOD SHAKES ❑
I,as owner of the property,or my employees with wages as their sola compensation,will do
the work,and the structure Is not intended or offered for sale(Sec.7044,Business and Profes.
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES E]Improves thereon,and who does such work himself or through his own employees,provided that
such improvements are not Intended or offered for sale.ll,however,the building or Improvement _
is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHE_R(SPtCIFY) ❑
not build or Improve for purpose of sate.).
❑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 Pla(d),gDE I .�,Qy�EPORT NO.
apply to an owner of property who builds or improves thereon,and who contracts for such projects la66DD Ae `Jy9
with a comractor(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR. INSTALLATION SPECS.
❑I am exempt under Sec. e 8 P.C.for this reason CIO VI'
LUrtH I INQ
Owner Date APPLICATION DATE VALUATION PER FEE
WORKER'S COMPENSATION DECLARATION '
I hereby affirm under penalty of perjury one of the fallowing declaration: ps n I,�,
❑I have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, 4— Li B �y Building
as provided for by Section 37W of the Labor Code,for the performance of the work for which this
permit is Issued. ^T Seismic
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of OCT ��
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's ILS\,•/^/' Total
Compensation Insurance carrier and Polity number are: 5 ��.
n rn.
Carrier Poesy No. PERMIT(AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑ �• ` — �O 8
(Thio section need not be completed it the permit Is for one huntlred tlollars($100)ar lees.) V FVGYG�KU/�1
I certify that in the performance of the work for which this permit is Issued,'(shell net employ
any person In any manner so as to become subject to the workers'Compensation Laws of can- All roofs shall be inspected prior to any rooting 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.
subjectto the WorkereCE TO CCompensation ANT. If,after provisionis ofthetabor Code you musufoinwitte omply 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 All roof coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentiened property for In-
spectionpurposes.
(We) ,� f W o _ l
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, • w (/
. judgments,costs and expenses which may In any way accrue against said City in consequence SIGNATURE 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