R-4557 APPLICATION FOR CITY OF CUPERTINO
NUMBER PERMIT
R- 4557
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
• 1lW DAYS FROM LAST CALLED INSPECTION.
BUILDING qDD E55
1 lir SAID n RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME roof assembly is required.
NO J Initial I.C.B.O.k
ADDRESS H 32. v�"t t.�5'fO^f PI�GI EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS '
CONTRACTOR'S
(] ZrO BE REMOVED Q TO BE RETAINED '
NAME (�Q�CA. L H �H �j &<s
ADDRESS TYPE OF ROOF COVERING
CITY a ZIP 1421*0_Cgill A,-k
EXISTING
PHON�-914 770 0 3 6 Z 9 4S'39 BUILT-UP ROOF ❑
LICENSE
NUMBER 7 `.39 ASPHALT SHINGLES �5
LICENSG
ED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license is In full force and
affect.
11-7WOOD SHINGLES ❑
License CIas9 C_31113 Lic.Number
O ❑
Osla ContraIXor OTHER (SPECIFY)
OWNER-BUILDE A PROPOSED
I hereby affirm that I am exempt from the Contractors License Law for the following reason.
(Sec.7031.5,Business and Protesslons code: Any city or county which requires a permit to
construct,alley,improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF/�1 ll E]applicant for such permit to file a signed statement that he Is Ilcensetl pursuant to the provisions Ol��
CI the Contractor's License Law(Chapter B(commencing with Section 7000)0f Dlvislon 3 of Lha (.�O
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES • yr [k
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500).):C]
$500).): WOOD SHAKES
C]I,as owner of the property,or my employees with wages as their sole compensation,will do ❑
the work,and the structure is not Intended or offered for sale(Sac.7044,Business and Profes-
sions Code: The Contractor's 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 awn employees,provided that
such Improvements are not Intended or offered for sale.II,however,the building or Improvement t
is sold within one year of completion,the owner-builder will he"the burden of proving that he did OTHER(SPECIFY) 3ol12s. 'f�.�
not build or improve for purpose of sale.). 1N ' 0
I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sac.7044,Business and Professions Coda:The Contractors License Law does not P OVIDE I.C.B.O. REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects API a contractors)licensed pursuant to the Contractor's License Law. P VI DE MFIWg4STALLATION SPECS.
I am exempt under Sac. ,B 8 P.C.for this reason
Owner Date APPLICATIOV'DATE VU VALUATION PERMIT EE .
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
Fj I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, Build!
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this /—
permitisissued. 9 ,S/�� 6 ��. Seismi
have and will maintain Workers Compensation Insurance,as required by Section 3700 of , I
i&�
_th Labor Cotle,for the performance of the work for which this permit Is Issued.My Workers
Compensation InsuI@nce carrier and Poll cynumber are: �V Total
Carrier�O we A �(�• POncy No.NL.31' PERMIT AUTHORIZATION
CERTIFICATE Of EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE IN 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 Bosse become s dc s Compansat�tn Laws or car- All roofs shall be ins any roofing material being
fornix. installed. If a roof is installed without first obtaining an
Dale! — Applica inspection,I agree to remove all new materials for inspection.
NOTICE T APPLICANT: If,after ma Is Certificate of Exemption,you Should ecome Applicant understands and WIII I with all non point
subject to the Workors'Componsatlon provisions or the Labor Cotle,you must forthwith comply pP comply Y P
with such provisions or this permit shat@be deemed revoked. Source regulations.
I certify that I have read this application and slate that the above Information Is correct.I agree
to Comply with all city and county ordinances and state laws rotating to building construction,and AIIr eclass"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes. 7 ^�
(We)agree s save,Indemnity and keep harmless the City ai Cupertino against liabilities, Q
.
judgments,the gran coats and expenses which may in any way accrue against said City Inconsequence SI ATUR- LICANT DAT
o7:
f the granting 01 this permit.
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATEINSP. 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