R 4675 APPLICATION FOR CITY OF CUPERTINO
NUMBI ERR- 4675
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
RESIDENTIAL COMMERCIAL OTHER
OWNER'S ^ HAZARDOUS FIRE AREA
/�-f!YL- � �a�.�s VES ❑ II yes s I assembly
is req that. Class A
NAME W//s I reel assemdy is required.
�! _ / �--� � � n NO ❑ Initial I.C.B.O.M
ADDRESS Z-7 `Q 5 ^� l�t.c /,]X• EXISTING ROOF COVERING
PHONE 35 40 -7368 NUMBER OF EXISTING COVERINGS /
CONTRACTO 'S -
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS {O / `y ('TYPE OF ROOF COVERING
CIN&ZIP ( fO��g�' !�.n-. a EXISTING 6/t/Air
-
PHONE 7[y [ "' 7 G !35 BUILT-UP ROOLICENSE V1 I fF�J3 1g ❑
NUMBER / ASPHALT SHINGLES!Jt-�t,.y 96❑
LICENSED CONTRACTORS DECLARATION y/1UJ�`
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 lull farce and
effect. 4 WOOD SHINGLES ❑
License Class • Lic.Number 109`1
j OTHER(SPECIFY) ❑
Date Contractor
OWNER BUILDER DECLAR ION PROPOSED "(�y)C
hereby affirm that 1 am exempt from the Contractor's License Lew for the blowing reason.
(Sec.70315,Business and demolish,
or rep Code: Any city or county which requires also a permit to
constrapalcuct,elter,Improve,to file a signed statement
air eny mentrth prior toItsIssuance,to
the ns BUILT-UP ROOF ❑
applicant for such permit License Ills a slgnetl statement nci Ilca ctio 7000) f to the pro of the
of the ss and tProfstens Lew )or that 8(commencing. action]000)of for the 3 of the
exemption.
xe ptio end violation of Section
or that he Is exempt' and the heels for the alleged ASPHALT SHINGLES ❑
exemption.Any ltyof oft more offhafive 7031.5 hundr9 Yran plica permit subjects the applicant to
a civil penalty of not more then five hundrr4�tl.dp118r 5 WOOD SHAKES
❑I,as owner of the property,It y~Woyeeirwd a as their sole compensation,will do ❑
the work,and the structure Is not i 00 or off ale(Sec.7044•Business and oldies.
aeons Coad:The Convector's Lic w ply to an owner of property who builds or WOOD SHINGLES
Improves thereon,antl who doedsuc k r Through his own employees,provided ant ❑
such Improvemeets are not Int lio are or edea.ill however,the en building of Improvement
nIs tbuild or
year of for
ower-builderwillhavetheburdenofprovingthathedld OTHER (SPECIFY)
not build or Improve/or purpose dl aBle./
❑I,as owner of the property,em excYuseveey contracting with licensed contractors to construct �O 42
the project(Sec.7044,Business and Professions Code:The Contractors License Lew 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 a contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
[:]I am exempt under Sec. ,B 8 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to self-insure for worker's Compensation, Buildin
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this Q
permit Is Issues. JS /Or O / Seismic s.l //1
w R/heva
and will maintain Worker's Compensation Insurance,as required by Section 3]000/ ( - by
the Or Cotle,for the performance of the work for which this permit Is Issued.My Workers
Compens�etlon��ln Tr{an?carte antl Policy number are: C�1 Total
Carrier a4„4X_ Potty No57lr1s/�S7 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C�
(This section need not be completed if the permit is for one hundred dollars($100)or lass.)
I certify that In the performance of the work for which this permit Is Issued,I shall not employ
any Person In any manner so as to become subject to the Workers'Compensation Laws of Cell. All roof shJII 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 to
NOTICE
TO the Workers'Compefnsation provisions oftheflcate of Laborr Code,Exemption,
mustforthwithoecome comply Applicant understands and will comply with all non point
with such provisions or this permit shalQbe deemed revoked. sOUfCe 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 c9gerin to be c ss"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
ep(We) purposes. �3��10
(We)agree to neve,Indemnify and keep harmless me City of Cupertino against liabilities,
judgments,costs and expenses which may In any way accrue against said Clry In consequence
ofthegrantingofthispermit. SIGNATOR OF APPLICANT ' TE
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