R 4939 NUMBER R- 4939
APPLICATION FOR CITY OF CUPERTINO
PERMIT
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
7584 Holianderry Pi. RESIDENTIAL_COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
Karen Li/StWYES ❑ If yes—I urWarstand that a Class
Li/Steven Wang P, of assembly is required.
NO ] Initial I.C.B.O.ri
ADDRESS as above EXISTING ROOF COVERING
PHONE 996-1862 NUMBER OF EXISTING COVERINGS 2
CONTRACTOR'S
NAME AJAY Roofing TO BE REMOVED X TO BE RETAINED
r ADDRESS TYPE OF ROOF COVERING
P.O. Box 963 Campbell 95009
CITv s ziP' EXISTING
PHONE 265-5147 BUILT-UP ROOF ❑
LICENSE
NUMBER 224767 ASPHALTSHINGLES QCj
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am 11,11,10 under provisions of Chapter 8(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 Class C-39 Lic.Number t
Date 9/19/96 Con treclor Q1/1.10�Ri OTHER(SPECIFY) ❑ '�
OWNER-BUILDER DECIARATION PROPOSED J
I hereby affirm that I am exempt from the Conmactoes License Lew 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 Its Issuance,also requires the BUILT-UP ROOF Elapplicant 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 Qp Q
• Business and Professions Coda)or that he le exempt therefrom and the basis for the alleged ASPHALT SHLNG LES 1996
exemption.Any violation of Section 7031.5 by any applicant lora permit subjects the applicant to
RI
a civil penalty of not more than five hundred dollars($500).): v
E)1,as owner of the property,or my employees with wages as their sale compensation,will do WOOD SHAKES-I- , ❑
the work.and the structure Is not intended or offered for sale(Sec.7044,Business and Profes.
slons Code:The Contractor's License Law does not apply to an owner of properly who builds ar WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,provided that ❑
such Improvaments are not Intended or offered for sale.II,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 contractors)licensed pursuant to the Contractor's License Lew, PROVIDE MFGR. INSTALLATION SPEC
❑I am exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATIO ERMIT F
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penally of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, Blll�dl
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of 9/19/96 4,000.00 Seismic
the Labor Code,for the performance of the work for which this permit Is Issued,My Worker's
Compensation Insurance carrier and Policy number are: Total
Carrier State Fund PolicYNo. 0695900 PERMIT AUTHORIZATION DATE
s CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N,CQ
(This section need not be completed it the permit is for one hundred dollar.($100)or less.)
1 certify that In the performance of the work for which this permit is issued,1 shall not employ
any person In any manner so as to become subject arkers'Cpmpeneation Laws of Cali. All roofs shall be inspected prior to any roofing material being
fornia' f A1 installed. If a roof is installed without first obtaining an
Dat.9-f " —�� Applicant inspection,I agree to remove all new materials for inspection.
NTO OTICE
If,after
isflExemption,
luushould become
subject to he Workers'Compensation provisions of the Labor Cotl you mstkrfhwhcomply Applicant understands and will comply with all non point
with such provisions or this permit shafte deemed revoked. source regulations.
I certify that 1 have read this application and state that the above information Is correct.)agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof coverings to be C"Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in- t•A� �_'���
spe) purposes. 49
(W
(We)agree to save,indemnify and keep harmless the CITY ai Cupertino y n cot liabilities,
ofthe gran costs and expenses which may In any way accrue against said DIIY4n consequence
of granting of this permit. SIGNATURL OF APPLICANT 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
nFFIl rnov