R 4866 PERMIT R_ 4866
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
• 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS /
D G. [ FIESIDENTIAL)L COMMERCIAL OTHER
OWNER'S >„ny�� �'/�� p q HAZARDOUS FIRE AREA .
NAME CSU �?Yl diM� 11��� YES ❑ roof assembly
is required. ClassA
roofIf s-I understand
n ty is required.
/Sy9S co eo �c�c[• 5f�/a NO Initial_ LC:B.O.s
ADDRESS— � Z.,,= /'-49-• 9b�i.�a -a65"� EXISTING ROOF COVERING
PHONE Q r NUMBER OF EXISTING COVERINGS
CONTRACTOR'S p /
NAME S �� �179f/.-✓iLt �A n /iy1L' TO BE REMOVED_, ____J_- TO BE RETAINED
ADDRESS f 9�� -� /� ,�� n - TYPE OF ROOF COVERING
CITY&ZIP / -P Z! .9-(iY/ Jr.///�. !/i(/S 7�62
EXISTING
PHONE -7 II `7l0�- T!�`7 �I BUILT-UP ROOF ❑
LICENSE
NUMBER ICENSEASPHALT SHINGLES ❑
LD ONTRACTORS DECLARATION - /
hereby affirm that I em licensedunder provisions of Chapter B(commencing with Section WOOD SHAKES
7000)of Division 3 0l the Business antl Prcleeslona Code,entl my cense Is In lull force entl
affect n• WOOD SHINGLES ❑
License Claes.C-12? Llc.Number L& Q
/!—/-�2 OTHER(SPECIFY) ❑
Data Contractor
OWNER-BUILDER DECLARATI N
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 BUIL- ROOF ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Lew(Chapter 0(commendng wlth Section 7000)of Divlalon 3 of the
. Business and Professions Code)or that he Is exempt tllerelrom and the basis for the alleged ASPHALT SHINGLES - ❑
exemption,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).):
E]1,as owner of the property,or my employees with wages as their sola compensation,will do WOOD SHAKES ❑
the work,and the structure Is not intended or offered for sale(Sec.7044,Business and Profes-
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑ LT T'L�
Improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for sale.If,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY)
not build or Improve for purpose 01 61110.)
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct pp9
the project(Sec.7044,Business and Professions Code:The Contractors License Law 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 aam exempt
tlicensed pursuant to the Contractors License Lew, PROVIDE MFGR.INSTALLATION SPECS.
❑I em exemptpt under Sea ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following deciaratlon:
❑1 have and will maintain a Certificate of Consent to aeihinsurs for Work I's Compensation, /-7�AO
as provided for by Section 3700 of the Labor Code,for the performance of thrwork for which this Building/ /V = 17
Permit is Issued. /o n
p D I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of DO Seismic 4O
the Labor Code,for the performance of the work for which this permit is issued.My Workers �.
Compena n Insurance" ca�rrier and Policy number are: Total ?[r9L
Cern l2'i/d > !; l - PolicyNOAk2CZln!n*IZ26 PERMIT AUTHORIZATION DATE
�—CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be Completed II the permit Is for one hundred tlollers($100)or less.)
I certify that in the performance of the work for which this permit Is issued,I shall not employ IVVV/ tlJ 1 l
any person In any manner so as to become subject to the Workers'Compensation Lawpt GQII-a All roofs shall be inspected prior to any roofing material being
fornla. Y 6� installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If.alter making this Certificate of Exemption,you s p�cuo�eer� �n�1�1�p!,��
subject to the Workers'Compensatlon provisions of the Labor Cotle,you must for mA9 eu$t 4plicant understands and will comply with all non point
with such provisions or this permit shell be deemed revoked. Source regulations.
I certify that l have lead this application and state that the above informationpppWpr!act��legroe
to comply with all city and county ordinances and state laws relating to building bohstrudtldF,MW` A11 roof coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spection purposes.
(We)agree to save,indemnity and keep harmless the City of Cupertino aggainst liabilities,
judgments,Coate and expenses which may In any way accrue against said City In consequence
. of the granting of this permit. SIGNATURE 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