R 4806 PERMIT R_ 4806
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
WI180 DANS FROM LAST CALLED INSPECTION.
BUILDING ADD1RESS/{� 1^
?art S , ` `� ``�> RESIDENTIAL)C COMMERCIAL OTHER
O NER'S udg /J vw V 11 e_ ./ j HAZARDOUS FIRE AREA
NAME e�� CO rill ?V_Q VL'N Uel0 VES ❑ If yes s I assembly
is req that a Class A
15495 L.OS qQ S nal assembly is required.
c J NO ❑ Initial LC.B.O.q
ADDRESS Q� Q S�3Z 2�I'� EXISTING ROOF COVERING
PHONE
`, NUMBER OF EXISTING COVERINGS
CONTRA S
TO BE REMOVED TO BE RETAINED
NAADDRESME q ,'may
N A ZIP Ins ���h a TT /.QJ 940 } EXISTING TYPE OF ROOF COVERING
PHONE (11b�0` l ��/ll�/I BUILT-UP ROOF ❑
LICENSE �qqJ f� b
NUMBER (iW r� ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
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 tome and
effect. WOOD SHINGLES
�J C�'
License Claes " Lid.Num or
D L I ❑
Data Contractor
OTHER(SPECIFY) �q ❑
OWNER-BUILDER DECLARATION PROPOSED .4
hereby affirm that I am exempt from the Contractor's License Law for the following r on.
(Sec.7031.5.Business and Professions Code: Any city or county which requires a permit to ��%b p
construct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF V,n ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provialons Vp�
of the Contractors License Law(Chapter B(commencing with Section 7000)of Division 3 of the ,
Business and Professions Code)or that he Is exempt therefr nd,the basis for the alleged ASPHALT SHINGLES"` ❑
e ciexevil penalty of dolt morefthantion five hand ed31.5 yyyoilsis($5001 bre It'eubjects the applicant to 4/
❑I,as owner of the property,or my arppfoyeea with wag Get compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or o red for is Ausneee and Proles.
alone Code:The Contractor's Licensepw d not e I -n of property who builds or WOOD SHINGLES
Improves thereon,and who does such wprk msell h his own employees,provaid that ❑
such Improvements are not Intended or olfe all If,however,the building or Improvement T I
Is sold within one year of completion,the olv or wlll have the burden of proving that he did OTHER(SPECIFY) Nszy�e —JAY4tt
not build or Improve for purpose of sale.). �1
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O. REPORT NO. L
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a comedians)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
01 am exempt under Sec. ,S$P.C.for this reason
OwnerDate
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PER FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Concent 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 1 g
permit is Issued,and700 of -1 1 Seismic 10
❑ have end will the performance
Workers f the work
for which ce,this as required by d.Section Workers
1111 b Uil
the Labor Code,for the pad for ance of the work lar which this permit Is leauetl.My Workers
Compan Ion Insurance carrier a?Leo Ilcy number are: �]1 Total
Carrier � l ; fi'CA1%17 Policy No�` • �95105 '2 PERMITAUTHORIZATI N DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.D
(This section need not be completed It the permit Is for one hundred dollars($100)or lees.)
I 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 Ceti All roofs shall be inspected prior t a fing material being
fornia. installed. If a roof is installed without first obtaining an
Date ` _ I ' Applicant inspection,I agree to remove all new materials for inspection.
NOT CE TO APPLICANT: ou
subject t.the Workers'Compensation provialons of thelLaborr Code,cate yoiu Of onmust fo thwiithbecome comply Applicant understands and will comply with all non point
with such Provisions or this permit shall be 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-
spection purposes. y
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
judgments.costs end expenses which may in any way accrue against said City In consequence
on heg.nlln.atthis, thin, 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPV ,