R 4737 APPLICATION FOR CITY OF CUPERTINO
PERMIT R- 4737
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
'
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
WI180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS ,
Lk1 i`,+-rr Ow. y
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
TT�..,� ►A VES ❑ It yes—1 understand that a Class A
NAMES Matx1ctA «f assembly is required.
t/� NO Initial I.C.B.O.H
ADDRESSawACL/�'4�'j"�'S/tGA ICT l..l.✓JRn,�' v, EXISTING ROOF COVERING
.
< NUMBER OF EXISTING COVERINGS /
PHONE
CONTRACTOR'S
` 1 TO BE REMOVED 7 TO BE RETAINED
NAME( )e3l 'X
ADDREST p.� TYPE OF ROOF COVERING
CITV&ZIP O
�] �7 EXISTING
PHONE-57 5 9— 7 / BUILT-UP ROOF ❑ �a
LICENSE
NUMBER Co (1 3 3 � ASPHALT SHINGLES [.�.
LICENSED CONTRACTORS DECLARATION /
hereby affirm mat I am licensed under lona of Chapter 6(commencing with Section WOOD SHAKES ❑
7000)of Division 3 0l the Business andndProfessions Cade,and my license Is in lull force and
effect. TT Fir WOOD SHINGLES ❑ �/
License Class ITT Dc.Numb r J ✓ Cv
Date Contract OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors 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 El
for such permit to file a signed statement that he Is licensed pursuant to the provisions /
' of the Contractor'sioe Lew(Chapter a(commencing with Section 7000)of Division 3 of the LJ
Business and Professions Code)Drina.he Is exempt therefrom and the basis for the alleged ASPHALTSHINGLES
exemption.Any violation of Section 7031.5 by any applicant fare permit subjects the applicant to
a dhundred penalty of not more then live huntlretl tlollars($500)J:
El 1,as owner of the property,or my employees with wages a$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 Con.radors 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 employees,provided that ❑
such Improvements are not Intended or offered for sale.It,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) El
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 Contractors 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 contractor(a)licensed pursuant to the Contractors License Law, PROVIDE MFGR.INSTALLATION SPECS.
C]I am exempt under Sec. ,8 a P.C.for this reason
Owner APPLICATION DATE VALUATION PERMIT.EU
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: 10 [v fes,
❑1 have and will maintain a Certificate of Consent to self-insure for Workers Compensation, N O W Q e- BUlldl
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this !� Z//)
permit le ued. ISN 25 ✓ 7(� $elSrl'11C
have entl will maintain Worker's Compensation Insurance,as required by Section 3700 01 A/ ra��
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's `�
TotalCompensetlon Inauranecarryer are: 12- G )t ERVISi(AITHORIZATION
DATEComePolicy No.n5
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O 1 ^
(This section need not be completed It the permit Is for one hundred dollars($100)or lees.) 1 L
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 sub or
to the Workers'Comp nsation Laws of Can. All roofs shat be inspected prior to any roofing material being
lornia. g installed. If a roof is installed without first obtaining an
Dare — 25 G 6 Applicaninspection,I agree to remove all new materials for inspection.
NOTICE TO s' after osnisosodayluushould become
subject to the WorrkereCompensatlon provisions he Labor of
mstfothwhcomply Applicant understands and will comply with all non point
with such provisions or this permit ehalf.be deemed revoked. source regulations.
I certify that I have read this application and stale that the above information Is correct.)agree
to comply with all city and county ordinances and stale laws relatingto buildingconstruction,and All rspection purposes. (((���pppf cover)n It las C"Or better.
hereby authorize representatives of this city to enter upon the abve-mentioed property kr In. { //
(We)agree to save.Indemnity and keep harmless the City of Cupertino against liabilities,
ofthe granting of this percosts end mit ea which may In any way accrue against said City In consequence $I ATURE 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
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