R 4802 APPLICATION FOR CITY OF CUPERTINO NUMBER R' 4 8 02
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 T (J(�,
f` y RESIDENTIAL_ _COMMERCIAL OTHER
OWNER'S (2 iA l fe,.{44rib V'- ( 0.gP Ar . HAZARDOUS FIRE AREA
NAME J6 ll/O N 1T QM' ZV1C..J— YES ❑ If yes s I assembly
is req that. Class A
C'f,f c /� I roof s-I understand
n a is required.
ADDRESS I`� `�v LAS (9'Q'�5 �Itf �- ID NO ❑ Initial I.C.B.O.tt
EXISTING ROOF COVERING
Los 0—&fvs, 9S i32 ^ZS P NUMBER OF EXISTING COVERINGS
PHONE40B—3$
CONTRACTOR'S
S TO BE REMOVED TO BE RETAINED
NAME
ADDRESS In C,c, I __I - _� Ivy /��,/3 EXISTING TYPE OF ROOF COVERING
cinszlP__LRD l�`Vlw / aq `1 T
PHONE (0 a 1 1 BUILT-UP ROOF Cl
LICENSE 1 1 ❑NUMBER 1 l ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(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 ❑
License Clecs o Llo.Number
I � I^ OTHER(SPECIFY) �„ ❑
Data it W Canco.,
n
OWNEm-BUILDER DECLARATION PROPOSED "V
hereby affirm that am exempt from the Contractor's License Law wforhich
the following reason. n
(Sac.7031.5,Business and Professions Code: Any city or county which requlrea a permit to /1 �/
construct,eller,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF �I ,,9
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions Q/of the Contractor's License Law(Chapter B(commencing with Section 7000)of Division 3 of the
Business and Professions Coda)or that he Is exempt lbscafrom and the basis for the alleged ASPHALT SHINGLESr iu,
exemption.Any violation of Section 7031.5 by any eppl 4 permit subjects the applicant to
a civil penalty of not more than five hundred dollsrR($500).
❑1,as owner of the property,or my emplogeas wg air sole compensation,wlil do WOOD SHAKES ❑
the work,and the structure is not Intentlsd or offers a at,7044,Business and Protee-
aloneCode:TheConirector'eLicense wdoesn oenownerolpropertywhobulldaor WOOD SHINGLES
Improves thereon,and who does eucN / il Rp rough hie own employees,provided that ❑
such improvements are not mien eQ 9 o I to ale.II,however,the bulltlinp or Improvement ^
oto within one year of completlo he ild will have the burden of proving that he did OTHER(SPECIFY) qI LT,'TIIe—I.JLI� r
nO'so or prove for purpose of Sale.).
❑I,asownerof the property,am exx melvely connecting with licensed contractors to construct '2
the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO. s I
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with acontexempt under
pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS. _
❑I em exempt untler Sac. ,B 8 P.C.for this reason
Owner DatAPPLICATION DATE VALUATION PER FEE
WORKER'S COMPENSATION DECLARATION .
I hereby affirm under penalty of perjury one of the following declaration:
r ❑1 have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, BUlldln
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this ...
permit Is Issued, I I _ I_O /_ B0 Seismic
❑ have and will themaintainrt Worker's Compensation the wokfor Insurance,as requiredsu Section 3700's `-'� / �J
the Labor Code,for the performance of the work for which this permit is Issued,My Worker's
Compenee�tl`Qn Ineurenc carrier antl Policy number are. r Total
Carrier `- ; fuVNC) Policy No.571 - 9`'IPS87 PERMITAUTHORIZATI
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.I]
(This section need not be completed If the permit Is for one hundred dollars($100)or IeseJ
1 certify that In the performance 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 Cali- fS S all 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.
subject lloo the WorkereCC Compensation ion after making
ov amns of thelcate of Laborr Code,Exemption.
must forthwith become
comply Applicant understands and Will comply With all non point
with such provisions or this permit shall be deemed revoked. source regulations.
1 certify Nat I have read this application and stale 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.
spection purposes.
We)agree to save.indemnity and keep harmless the Clry of Cupertinoepalnst liabilities,
judgments,costa and expenses which may In any way accrue against said City In consequence
of the granting of this permit. SIGNATURE OF P ANT 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
, _I OFFAce-cOPY - I I