R 4768 PERMIT
APPLICATION FOR CITY OF CUPERTINO
NUMB RR- 4768
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 IN6PECTION.
BUILDING ADDRESS
V V-n OL re- RESIDENTIAL ZOMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
NAME m (L �.J I S\"J� VES ❑ If yes s I assembly
req that. Class A
t roots-I nbl Isr required.
• NO ❑- Initial I.C.B.O.#
ADDRESS S nmQ. EXISTING ROOF COVERING
PHONE
NUMBER OF EXISTING COVERINGS. '
CONTRACTOR'S
NAME LA-)Air(-,-j I�� TO BE REMOVED TO BE RETAINED
ADDRESS D I �Ok 3ss�3 - i-- TYPE OF ROOF COVERING
CITY&ZIP
EXISTING
PHONE 33J BUILT-UP ROOF ❑
LICENSE ❑
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed 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 farce and
effect. WOOD SHINGLES ❑
License Clave G3 9 Llc.Number Z-,
OTHER SPECIFY
Date S��' q L+* Cont racmr (SPECIFY) ❑
OWNS -BUILDE RATION PROPOSED
I here0y affirm that 1 em exempt fro e�Cpnlreclore License Lew for the following reason.
(Sec.7031.5,Buslneae end Proleselons d&i Any city or county which requires a permit to
construct,alter,improve,demoivir,
rre jtructure,prior to He Issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to filee a rent that he Is licensed pursuant to the provisions
of the Contractor's License La ( ommencing with Section 7000)of Division 3 of the
Business and Professions, r e Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES ❑
exemption.Any viol n f 031.5 by any applicant for a permit subjects the applicant to
a civil penalty of n h undred dollars($500).): WOOD SHAKESI,ae own - ep arty,omy employees with wages as their sole compensation,will do ❑
the work,antl 6 rrture is not Intended or offered for sale(Sec.7044,Business and Profes.
alone Code:The Con ractore License Law does not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who tloee such work himself or through le 0 n employees,provided that ❑
such improvements are not Intended or offered Mr Bale IL ho i, a but Ing or Improvement / 'Fi Y! F✓•'A—R
Is sold within one year of completion,the owner-b de will he eth of proving that he did OTHER(SPECIFY) Kry-15 ,x r,
not build or Improve for purpose of sale.).
C]1.as owner of the property,am exclusively nt cting Ithl d contractors to construct
the project(Sec.7044,Business and Profession Cotle;The Co fro or's License Lew does not PROVIDE I.C.B.O.REPORT,NO.n,
apply to an owner of property who builds or Improves thereon,and who contracts for such projects `'; La u
with a contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B&P.C.for this reason ^�
Owner oats APPLICATION DATE V TON y ,PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: ryuvY
Cl 1 have and will maintain a Certificate of Consent to self-Insure for WorkerUr
Compensation, �•I I 1 U Building /
ae provide or by Section 3700 of the Labor Code,for the performance of the work for which this g
permit asued.
have and will maintain Worker's Compensation Ineurence,as rewired by Section 3700 01G Seismic r O
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 ST14TE PyyVQ pollcyNo.")—ty"1oS59-4(o PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.p .
(This section need not be completod If the permit Is for one hundred dollars($100)or leas.) (J[✓
I certify that In the performance of the work for which this permit is Issued,I shall not employ 1i
any person In any manner so as to become,subject to the Workers'Compensation Laws of Can. All roofs shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date App llca t inspection,I a ree to remove all new materials for inspection.
subject to EhaOworkarsCCompefneetlo V lonle fir eb Code,of you mual lonhwllthbecomecomply APPI' unders rids and will comply with all non point
with such provisions or this permit shell a deemed r v ked. S Ce regulation .
I certify that l have read this application and state the the Above Information is correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,antl II roof COveri g to be class"C"or bett r.
hereby authorize representatives of this city to enter upon the abova-mentioned property for In-
spectionpurpoeee. 2,J
(We)agree to save.Indemnity and keep harmless the City of Cupertino against liabilities, - S /rp
judgments,wets and expenses which may In any way accrue against said City in consequence
of the granting of this permit. SI TORE 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
OFFICE COPY