R 4816 PERMIT R_ 4 816
APPLICATION FOR CITY OFCUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
1• 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
14 't �(� 12t7 1�tr RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRIF AHIll
S VES El If yes—I understand that a Class A
NAME fr\ J ✓ �✓t r'L " ' roof assembly is required.
�} �( y1 NO l74 Initial I.C.B.O.#
ADDRESS �" Y � 'l �eT-e0� y^ �AeI71� 9 EXISTING ROOF COVERING
PHONE — Ct of O C NUMBER OF EXISTING COVERINGS
CONTRACTOR'S /+
NAME OD{� Q S I_P✓'� l TO BE REMOVED TO BE RETAINED
ADDRESS ` 6 1 0 7 Lo S (,a 7-05 u(WL a ctch ✓tN EXISTING pfliYPE OF ROOF �
C� 4,-
�p �!
PHONE -� 1 � — BUILT-UP ROOFLICENSE
�G!
NUMBER ASPHALT SHINGLES - Fd p
LICENSED CONTRACTORS DECLARATION `gyp
I hereby affirm that I am 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 force and
effect. WOOD SHINGLES ❑ G6
License Claes C 3 Llc.Number 6' ` a � � G
Date �' 6 contreaor RI d P/74 Ctf rrr OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED fa
I hereby affirm that I am exempt from the Contrectoea License Lew for the following reason. O
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to q
Construct,alter,improve,demolish,or repair any structure,prior to its Issuance,also requires the BUILT-UPROOF #�ry/� 7 ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions d
of the Contractor's License Lew(Chapter 9(commencln with Section 7000)of Division 3 of the C/r
. Business and Professions Code)or that he Is exempt tharefrom and the basis for the alleged ASPHALT SHINGLES 19
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to G/,;
e civil penalty of not more than five hundred dollars($500).):
01,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 sate(Sec.7044,Business and Profee-
sionsCom:The Contractor's License Law 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 sate.If,however,the building or Improvement
Is sold within one year of completion,the owner-bullder 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 Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
E)I am exempt under Sec. ,B 8 P.C.for this reason
Owner oats
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 self-insure for Workers Compensation, BUIlding
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit Is Issued.vandSeismic ,r ❑ have end will maintain Worker's Compensation the work
Insurance,as required by Section 3700's /�
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's d
Compensation fence c.8eer an licy number are:
l ' TOteI
Carrier YY.nee Policy No. PERMIT AUTHORIZATION DATE
CERTIFICA OF EXEMPTION FROM WORKERS'
COMPENSATION it is INSURANCE N.C.p /L
(This section need not be completed If the permit la for on undrod tlollare($100)or Ieae) MV
I certify that In the performance of the work for which th rmlt Ie leaueq I shall not employ
any portion In any manner do as to become subject to t orkers'.Co Laws of call- All roofs shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date " Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLIC NT: If,after making run of xemptlo ou sl Itl become Applicant understands and will Comply with all non point
subject to the Workers'Compensation provi a ebo otle,you ust forthwith comply PP P Y P
with such provisions or this permit shall be deem revoke source regulat nS.
I certify that l have read this application and eta that above Information le correct.l agree
to comply with all city and county ordinances and et we relating to bulltlingcgnetructlon,entl All r0=/666'Go C 'C"or better.
hereby authorize representatives of this city to enter upon the above-mentloned property for In.
spection purposes. or
/.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
judgment%costa and expenses which may In any way accrue against said City In consequence
of the granting of this permit, SI A DATE
• PRE-INSPECTION: PLYWOOD: IN-PRO GR S:
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 �.