R 4691 PERMIT R_
APPLICATION FOR CITY OF CUPER1 NUMBER 4 6 91
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777.3225 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
1 180 DAYS FROM LAST CALLED INSPECTION.
J5WILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S j� ` HAZARDOUS FIRE AREA
NAME DA 0e, 13 ;a1, N� YES ❑ It yes—I understand that a CIM,A
root assembly is required.
.� NO - Initial LC.B.O.N
ADDRESS_ 400 /"1^/t I A /v I A \! F EXISTING ROOF COVERING
d
PHONE -1-O S J — '-+ Z NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME— � rS P-0 0-f 1✓�C- G 0 • TO BE REMOVED `/f S TO BE RETAINED
ADDRESS 1 -40 S O N h , S/`f/1 ,J��. TYPE OF ROOF COVERING
CITY d ZIP
EXISTING
PHONE- 41S 9(0 "7 — Z—n C/ BUILT-UP ROOF
LICENSE O
NUMBER S ASPHALTSHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is in full fares end
ahem. WOOD SHINGLES El Claes Lie.Number
Date Contractor
OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's 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
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions -
of the Contractors License Lew(Chapter 9(Commsncinlp with Section 7000)of Division 3 of the
Business and Professions Code)or that he Is exempt tharslrom and the basis for the alleged ASPHALT SHINGLES Elexemption.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($500).):
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sac.7044,Business and Proles.
alone Code:The Contractors License Law does not apply to an owner of property who bullds or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees, rovided that E]such Improvements are not Intended or offered for sale.II,however,the building or Pmprovement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not b or Improve for purpose of sale.).
s owner of the property,em exclusively contracting with licensed contractors to construct
the reject(Sec.7044,Business and Professions Code:The Contractors License LBW does not PROVIDE I.C.B.O.REPORT NO.
ap y to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractogs)licensed pursuant to the Contractors License Law.
❑I am axe fy un or Sec. ,B$P.C.for this reason PROVIDE MFGR.INSTALLATION SPECS.
Owner—i Data
WORKER'S COMPENSATI NDECLARATION APPLICATION DATEI VALUATION PERMIT FEE
I hereby affirm under penalty of penury one of tl a following declaration:
E] P � ' "�
I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for Which this I�
permit leve and y QQ q{t Seismic 1L 10
❑ have and will the peirf Workers Compensation which this as required by d.My
3700 of OCT d 3 R
aha Labor Code,for the pertormand of the work for which This permit le Issued.My Workers O
Compensation Insurance carder and Policy number are: Total
Carrier Policy No. MIT ACTH RIZATION
CERTIFICATE OF EXEMPTION FROM WORKERS' DATE
COMPENSATION INSURANCE N.C.o 1�
(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 so as to become Subject to the Workers'Compensation Laws of Cell- All roofs shall be inspected pri any roofing malbrial being
forni9. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It,after making this Certificate of Exemption,you should become A Ilcant understands and will cam
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP ply with all non point
with such provisions or this permit shalQbe deemed revoked. source regulations.
I certify that I have reed this application and state that the above Information le correct,I agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof C[y{prings to be class"C"Dr better.
hereby authorize representatives of this city to anter upon the above-mentioned property for In.
J
ep(We) purposes.
(W6)agree to save,expenses
end keep harmless the City of Cupertino against Ilebllltlee, 1 /
judgments,coats and expenses which may In any way accrue against said City 10 consequence
F APPLICANT
PRE-INSPECTIONof the granting of :
PLYWOOD: SIGNATURE ON-PROGRESS: DAT
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