R 4867 PERMIT
APPLICATION FOR CITY of CUPERTINO NUMBER R- 4867
REROOF PERMIT .INSPECTION DIVISION PERMIT EXPIRATION
(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
D RESIDENTIAL COMMERCIAL OTHER
—
OWNER'S
C ;ry� jl/Q,4il- IL7pq HAZARDOUS FIRE AREA
NAME '-Hot -"Q-,11 k��✓Ct VES O/ I�assenn�pty is required.
egtand tat. Class
r NO _4 regw lnn'Itial I.C.B.O.N
is496 Lo�tos td/✓c� ;stL/O
ADDRESS L—�/✓f¢. rA. 9tf03a -,9Sy�! EXISTING ROOF COVERING
PHONE Qp - - NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S J. /�
NAME—S"—�jJ� C�� o��iyl G• TO BE REMOVED TO BE RETAINED
O TYPE OF ROOF COVERING
EXISTING
PHONE_416 A 76 5;, BUILT-UP ROOF ❑
LICENSE a
NUMBER /D ASPHALT SHINGLES ❑
LICE ED CONTRACTORS DECLARATION
hereby iaffirmnion that em si nes under provisions of Chapter a(commencing with Section WOOD SHAKES
7000)of Division 3 0l the Business and Professions Code,and my license Is In lull loroo and
'
alias. SHINGLES ❑
License Claes `-�J / LIc.Number 0*109/
Date—y4 Contractor_�i 1�J/�'1 '� .^�-y-` OT (SPECIFY) ❑
OWNER-BUILDER DECLARATION/ PROPOSED
1 hereby affirm that I am exempt from the Contractor's License Law for the following reason.
IS
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 theBUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions
of the Contractor'.LlcenSB Law(Chapter g(commencing with Section 7000)of DIvIslon 301 the
• Business and Professions Code)or that he In exempt therefrom 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).):
❑1,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 Sale(Sec.7044,Business and Profes.
sions Code:The Contractors 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 sale.II,however,the building or Improvement 7�
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 of sale.). IX IXI T _-.// l%
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Profess one Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds of Improves thereon,and who contracts for such projects
with a contractor(.)Incensed pursuant to the contractors atones Lew. PROVIDE MFGR. INSTALLATION SPECS.
❑I em exempt antler Sec. ,B 8 P.C.for this reason
Owner Aare
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: ww
O
❑1 have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, BUId In
as provided for by Section 3700 of the Labor Code,for the performance of me work for which this ,/ Gaff g
permit Is Issued. /(L 3
I have and will maintain Workers Compensation Insurance,as required by Section 3700 o1 / , Seismic
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's /�� e!0
'Compensatl n Insurance carrier and Policy number are: /c D,4 - Total T
cafri.r l�7ay Vi95. �� Policy No.Gllf / .J&ai _ PERMIT AUTHORIZATION DATE
17 CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NO.p
(This section need not be completed If the permit is for one hundred dollars III or lees.)
I certify that In the performance of the work for which this permit Is Issued,1 shall not employ G�
any person In any manner so as to become subject to the Workers'Compensation Laws of Cell- All roofs shall be inspected prior to any roofing material being
fomia. installed. If a roof I,%installed without first obtaining an
Data Applicant inspection,I agree to er*#pJ new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant unde gds and will Comply with all non
subject to the Workero'Compensatlon provisions of the Labor Code,you must forthwith comply �fTsll' 2 p y point
with such provisions or this permit shalgbe deemed revoked. Sol regUI811
1 certify that I have read this application and state that the above Information la correct.I agree Ad�,�/nQ p,,
to comply with all city and county ordinances and state laws relating to building construction,and All roof COV4111ir ��O b!cfEs or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spectlon purposes. V Llrc,r flr sU 9
(We)agree to Save,Indemnify and keep harmless the City of Cupertino against liabilities. �' 29' l J
judgments,coats and expenses which may in any way accrue against Said City In consequence
. of the granting of thispermb. 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 COPY