R 4509 PERMIT
APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 450 .9
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 160 DAYS OF PERMIT ISSUANCE OR
160 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
'769(, NoPMA-i`JDy way ✓
RESIDENTIAL COMMERCIAL OTHER
OWNER'SS� / HAZARDOUS FIRE AREA
�.f �f�a.�! e Q 40 P�ll YES ❑ It yes-I understand that a Class A
NAME !� �7 w' r J `� root assembly is required.
NO Initial I.C.B.O.#
ADDRESS '745 8(p A)&I`m EXISTING ROOF COVERING
PHONE
s_, (0 NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S
a/j ✓e4-2 �w-tlr/��Q ��C TO BE REMOVED / TO BE RETAINED
NAME # 4�L /�" � �
ADDRESS '5014/ / G.__ J r, 0 TYPE OF ROOF COVERING
77 ��5f EXISTING
PHONE BUILT-UP ROOF ' Q Ifn❑
LICENSEASPHALTSHING4
' NUMBER y
LICENSEDdunderCONTRACTORSsof Chapter 9(N d 10�
I hereby Daffirmivision
that em Business
need under Professions
loss of Chapter g(commencing with Section WOOD SHAKE�S� v
7000)of Division 3 of the Business end Profeselops Code,and my license is In full tome and r lJP Vl%-Lry 1)l `
Lire" d� /�/ U o 0 If WOOD SHINGLES
License Claes vLic.Nu -+
( OTHER(SPECIFY)
Data Contractor-""Lf'
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors License Law lar the following r aaon.
IS
7031 .Business and Professions Code: Any city or county which requires a p m0 to
construct,al Improve.demolish,or repair any structure,prior to its issuance.also req reslhe BUILT-UP ROOF E /
applicant for suc stand to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's L rise Law(Chapter g(commencing with Section 7000)of Division 3 of the
. Business and Profassl Code)or that he Is exempt
the and the basis for the alleged ASPHALT SHINGLES El
exemption.Any violation a tion 7031.5 by any applicant for a permit subjects the applicant to Ilq h
e civil pastry of not more than hundred
pl dollars(h wag): WOOD SHAKES �
❑Las and wner
structure
I not
employeeswithWages eSec.7sole compensation,ndPrwill s-
the work,entl the Contractors
Is not Ince oras not for sale(Sea o an Owner
of Business and builds
o-
Improvsions Improves
thereon,and
asnot applyghhisowne property who idedt at WOOD SHINGLES ❑
Improves thereon,antl who does such work h elf ar through his own employees,improvement provided ant
such Improvements are not Intended or ogeretl f ale.If,however,the building or Improvement
Is sold within one year of completion,the owner-buil will have the burden of proving that he did OTHER(SPECIFY)
not build or Improve for purpose of sale.).
01,as owner of the property,am exclusively contractin Ith licensed contractors to construct y�
the project(Sec,7044,Business and Professions Code:The Contractor's License Lew does not PROVIDE I.C.B.O.REPORT NO. 1 1 1 r
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor($)licensed pursuant to the Contractor's License Law, PROVIDE MFGR.INSTALLATION SPECS.
1 am exempt under Sec. ,B&P.C.for this reason
OwnerDate
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm untler penalty of perjury one of the following declaration:
❑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 Coda,for the performance of the work for which this I//_��/ n�♦
permit Is Issued. Ip 10 l� l�J
p��'li�t99va and will maintain Workers Compensation Insurance,as required by Section 3700 of Seismic
_th6Lebor Code,for the performance of the work for which this permit is Issued.My Worker's
Compensation IQ once carrier and Policy number are: ��'I Total
Card-I�L�L Cd Policy No.` 2g6113032s PERMIT AUTH ON DATE
CERTIFIC E OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.E]
(This section need not be completed it the permit is for one hundred dollars($100)or less.)
I certify that In the performance of thew C
for which this permit is issued,I shall not employ
any person In any manner so a becom Tject to the workers'Compensation Laws of Cali. All roof.^.shall be inspected prior to any roofing ma e I being
fornia. VI l installed. If a roof is installed without first obtaining an
Dale Ap Il ant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,alter making this Certificate of Exemption,you should become
subject to the Workers'Compensation provisions of the Labor Corte,you must forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shelgbe deemed revoked. source regulations.
I certify that I have read this application and slate that the above information is correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,and A Of c0 Ings t0 be Class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
apache)purposes.
(We)agree to save,expenses
and keep harmless the City ai Cupertino against liabilities,
judgments,coats and expenses which may in any way accrue against said City In consequence
. of the granting of this perm0. SI NA URE 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
nFFIrF rnpv