R 4841 APPLICATION FOR CITY OF CUPERTINO NUMBER R- 4841
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 INSPECTION,
BUILDING ADDRESS \///�
MART(111 wooD ,#'V RESIDENTIAL COMMERCIAL OTHER
OWNER'S - HAZARDOUS FIRE AREA
NAME ,��'rT� Fig YES ❑ If yes—I understand that a Class A
roof assembly is required.
NO Initial I.C.S.O.#
ADDRESS 341 0 1?0IU A1R6 C7: JUAl .7'05t I EXISTING ROOF COVERING
PHONE ?F11 7 NUMBER OF EXISTING COVERINGS 1
CONTRACTOR'S p �1
NAME E-c ` q�"am f`dorlN(j co TO BE REMOVED 1 TO BE RETAINED d
CIT/GESSZlP 3b 3 tf�l�'f�ISO1V /g)/F TYPE OF ROOF COVERING
EXISTING
PHONE '`� BUILT-UP ROOF ❑
LICENSE
NUMBER SSS}LI6'1 ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby e#Irm that I em licensed under provisions of Chapter B(commencing with Section WOOD SHAKES 19
7000)of Dlvlsion 3 of the Business and Professions Code,and my license Is In lull force and
enact WOOD SHINGLES ❑
S&2 Llcenee Class � �� Lic.Number ��1
Date g111 j46 Contractor�— d I 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 atru re,prior to Its Issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement th a Is licensed pursuant to the prwislons
• of the Contractor's Llcenee Law(Chapter g(comment; with Section 7000)of Division 3 of the
Business and Professions Code)or that h16 exelfipt e(elrem and the basis for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031,5 a"n p Ifat a permit subjects the applicant to
e civil penalty of not more then 11 hum e 0
C]1,as ownerol the prop yor Iy It eysras their sole compensation,will do WOOD SHAKES ❑
the work,antl the structur e n t n r ere .toYsale(Sec.7044,Business and Profits-
Improves thereon,
a awpme not apply to an owner of property who buildsor WOOD SHINGLES
Improves thereon,end w o oes pch-work hinted I or through his own employees,provided that ❑
such Impadnot ndad or offered for sale.If,however,the building or Improvement
Is sold within one yee(plcoin etion,the owner-builder will have the burden of proving that no did OTHER(SPECIFY) ❑
not build or Improve far 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 Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who Wilds or Improves thereon,and who contracts for such projects
with a contractogs)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,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:
❑I have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, y T BUlldln
as provided for by Section 3700 of the labor Code,for the performance of the work for which thls CN /" g
permit Is Issued, SeiBmiD
have and will maintain Worker's Compensation Insurance,as required by Section 3700'e AP '�
tna Labor Cotle,for the performance of the work for which this permit Is Issued.My Worker's 1 7 �� Total
'Compensation Insurance terrier and Policy number are:
Carrier M'7C F41M) Policy No.�'SSJ� (3�rY U. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' `V'-'-
COMPENSATION INSURANCE N,C.p
(This section need not be completedIf the permit Is for one hundred dollars($100)or leas,) � \p.1/�+�(V']f�Y•--J �,(w/
I certify that In the pedormance of the work for which this permit Is Issued,I shell not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Cell. All rOOfn shall be inspected prior to any roofing material being
fornie. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
subject Ito the Workens CompeTO APPLICANT; nsateon provisions.of thellcate of Laborr Code,Exemption,
mustufo thwllitthcecome
comply Applicant understands and will comply with all non point
with such provisions or this permit shaipbe deemed revoked. Source regulations.
I certify that I have read this application and state 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. [ _
sP purposes.
(We)
(We)agree to save,Indemnify and keep harmless the Clry of Cupertino against liabilities,
ludgmenta,costa and expenses whlch may In any way accrue agalnsl Bald City In consequence ,
SIGNATURE OF APPLICANT DATE
of the granting of this permit.
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