R 4520 PERMIT R_ 4520
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
BUILDING ADDRESS
180 DAYS FROM LAST CALLED INSPECTION,
f�'�ol l�/
I is$ Ke Riwaoa Ove PsRESIDENTIAL k!::�COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
I YES ❑ If yes-I understand that a Class A
NAME CO 1 1 K u Z YII!_r roof assembly is required.
Q _I NO ❑ Initial I.C.B.O.#
ADDRESS 1`3''��/ Ar [phi .. IAhlo � we) A (-17U EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
OONTRAC7 15
on r
Ct ` TO BE REMOVED TO BE RETAINED
NAME
ADDRESS 3.321
3 2 p nsll TYPE OF ROOF COVERING
CITY 8 ZIP //,�,�� '1 EXISTING
PHONE 1_'tLl'f� 214-3(A 15 BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORSECLARA ION
I hereby affirm that I em 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 lull farce and
effect. WOOD SHINGLES ��
License Claes C �.9 Uc.Number ^ 2�I �5Z 1- A I' D
Dale 1O�1 9 V Contractor {.� Irwin AMOTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED ob 1^^Y 21996
I hereby affirm that I am exempt from the Contractor's License Lew for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
canetruct.alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF CIIY � wrtn UlNU
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
• of the Contractor's License Law(Chapter g(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
a civil penalty of not more than five hundred dollars($500).):
❑1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not intended or offered for sale(Sec.7044,Business and Profits.
alone Code:The Contractor's License Lew 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.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 Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improvers thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractors License Law. PROVIDE fill INSTALLATION SPECS.
C]I am exempt under See. ,B&P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: A
1 have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation,
es provided for by Section 3700 of the Labor Code,for the performance of the work for which this Building
permit is Issued. 412
$eISmIC
01 have and will maintain Workers Compensation Insurance,ars required by Section 3700 of
the Labor Code,for the performance of the work for which this permit Is Issued,My Workers
Compensation Insurance carrier and Policy number are: - Total Z,
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
If the A�
(This section need not be completed If the permit Is for one hundred dollars($100)or lace.) 7 '
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'Compeneetlon Laws of Call. All roofs she I be inspected prior to any roofing material being
fornix' installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOT subject l.Ethe APPLICANT,
o kera Compensatio orovisionis o1 Certificate
CExemption,
de y lu must forthwithlbecame
comply Applicant understands and will comply with all non point
with such provisions or this permit shall be doomed revoked. source regulations.
I certify that I have reed this application and stele 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-mentioned property for in.
spection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costa and expenses which may in any way accrue against said City In consequence
•
of the granting of this permit, SIGNATURE 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 ACCESSTO ROOF SHALL BE PROVIDED.FOR INSPECTION
OFFICE COPY