R 4510 PERMIT R_ 4 510
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN DAYS OF PERMIT ISSUANCE OR
WI DAYSS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
(+�
/O 3�" v!"V v RESIDENTIAL tI COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
NAME v i- - ' V YES El roof assembly is thad.
t a Class A
(' /nJ � � __ NO - _ Initial C.B.O.#
ti ADDRESS `O 3& S' (�`�—• EXISTING ROOF COVERING
PHONE O/ 01 — ( � / NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S �� p p �j
/�/l S A.f�l� A TO BE REMOVED TO BE RETAINED
NAME 6- , 1
ADDRESS2 C9 . / L _ � p a G, TYPE OF ROOF COVERING
CITY&ZIP
EXISTING
PHONE BUILT-UP ROOF ❑
LICENSE 513001NUMBER ASPHALTSHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter B(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business entl Professions Code,and my license le In lull force entl
effect. —/7 i WOOD SHINGLES ❑
License Class C 3 I Llc.Numb 51300
Date 7f Contract OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from the Contractors License Lew for the following reason,
(Sec.7031,5,Business and P10113 ns Code: Any city or county which requires a permit to
construct,alter,Improve,call 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 Lew 1Chapter S(commeI 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�71.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more the Ilvaed dollars(11500)J:as owner of the pro er orp1{yeeswit gee as their sole compensation,will do WOOD SHAKESthe work,entl the etructur at Indor offered 1 spIs(See.7044,Business and Prates.
slant Cotls:The Contract Ic9nw do��nfot sp an owner of property who builds or WOOD SHINGLES
Improves thereon,and who oat such or self or ou hie awn employees,provided that ❑
such Improvements are no Intended bffe d/° a Mwever,the building or Improvement
le sold within one year of completkrb,the ow -b Il have the burden of proving that he did OTHER SPECIFY
not build or Improve for pu�oe uIji (SPECIFY) ❑
❑i,ee owner of p15q �m y ontrecting with licensed contractors to construct
the project Sec.7044,911{1 ass P alone Code:The Contractors License Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to or owner olprope dsorlmprovea thereon,and who contracts for each projects
with a contractor(e)license a aorto the Contractor's License Lew. PROVIDE MFGR. INSTALLATION SPECS.
❑ em exempt under SeO. ,9 6 P.C.for this reason
Owner Date APPLICATION DATEJ VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: (' p p
❑I have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, w1 ®yy BUildin /
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this e —k-1-7a
permlt�l Issued. �% $91SmIC
Jalheve entl wool the performance
Workers Compensation Insurance,as required by Section 3700 of Cr/�uh O �� �� \
the Labor Code,for ins penormance of the work for which this permit Is leeuetl.My Worker's
Compe�nspation In ranee carrier en/g��Polley numbarere: Total
Carried I �lVll.Os l-•_OGY'SI I�;�a Zv9�1130 Sas" ` '
PERMIT AUfTHORIZATION DATE
CERTIFICATEEMFINSUFROM WORKERS'
COMPENSATIONIf theINSURANCE 100)o
(This section need not be completed If ins permit Is for one hundred dollars($100)or IeaeJ
I certoty that In the performance of the work for which this permit Is Issued,I shell not em toy
any person In any manner so as to become subject to the Workers'Compeneetlon Laws of Leen- All roofs shall be inspected prior to ny roof g m rial being
°role' installed. If a roof is installed without first obtaining an
Dater{Ilea inspection,I agree to remove all new materials for inspection.
subject to
NOTICE
WT.
oPkereCComp rtes m kll Ionstyotthelcate LebarCotle,Exemption,
muetulorthwlltlhbecome
comply Applicant understands and will comply with all non point
with such provisions or tole p rmit all be deemed revoked. Source regulations.
I certify that l have read thi application entl state that the above Information le correct.)agree
to comply with all city and county ordinances and elate laws relating to building conatrucllon,entl pfl.fQOf COVeTIngSt lass"C"Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
ep'We' purposes.
g(We)agree to as
Indemnity and keep harmless the City of Cupertino apalnet Ilabllltlas, 40/7 q(e2
oldthe gaoling of this peand rmit ee which may In any way accrue epelnet sold Ciry Inconsequence SIGNATURE O P LICANT 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
OFFICE COPY (. " ' '