R 48640
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OFFICE COPY-
PERMIT R 4864
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DNISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S G,v}yrino- j /�¢
- HAZARDOUS FIRE AREq
-
./J n���
VES ❑ If yes— I understand that a Class A
NAME -0-70C i� .ri
, /
loot assembly is required.
NO Inmaf I.C.B.O. a
�/�,5/9s rY� Q,po /c�/✓C(j s 2 /�
EXISTING ROOF COVERING
ADDRESs (1rapa,O //�. 95 %�3,�--,;�'� S!�
PHONE
NUMBER OF EXISTING COVERINGS /
CONTRALTO '
NAME �/�J'fyt 6h�—�' Com• ;�ih!
TO BE REMOVED _/__ TO BE RETAINED
ADDRESS /� y
TYPE OF ROOF COVERING
CITY&ZIP /��� �'Gyl (///i r'(�./� Z46
EXISTING
�
9s�,/-��
PHONE 9�
BUILT-UP ROOF ❑
LICENSE ��('
NUMBER
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
hereby
affirm that I em licensed under lona of Chapter 0 (commencing with rcecand
WOOD SHAKES
sin Professions
7000) of DIvl9lon 3 of the Business and Proleselons Code, and my license is In lull force entl
atlas].
G -3 /D %/
/15
SHINGLES ❑
Llcense Claes Uc. Number o742
Dale /—�� ConVactor , �z r, �>
.
OTH (SPECIFY) ❑
OWNER -BUILDER DECLARAT16N
I hereby affirm that I am exempt from the Contractor's License Lew for the following reason,
PROPOSED
(Sac, 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
BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractors License law (Chapter 9 (conlmencin with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and the basis for the
alleged
exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
ASPHALT SHINGLES ❑
a civil penalty of not more than live hundred dollars ($500).):
E] 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 Proles.
alone Code: The Contractor's License Law does not apply to an owner of property who builds or
Improves thereon, and who does such work himself or through his own employees, provided that
WOOD SHINGLES ❑
such Improvements are not Intended or offered for sale. If, however, the building or improvement
U T
soldwithin e r of completion, t owner -builder will have the burden of proving that he did
ntbuildat
OTHER (SPECIFY)
not provne sme
or Improve for purpose of
for purpose sale.).
❑ 1, as owner of the property, em 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 NQ/ 9
apply to an owner of property who builds or improves thereon, and who contracts for such projects
licensed Stlpursuantto the Contractor's license Lew.
with ac am
❑ I em exempt under Sac. ,B 6 P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner Date
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION
PERMIT FEE
I hereby affirm untler penalty of perjury one of the following declaration:
❑ 1 have and will maintain a Certificate of Consent to sell -Insure for Workers Compensation,
_ _
as mit [a foray Section 3700 0l the Labor Code, for the performance of the work Mr whichthis
permit le ed forIssued.
- /
L/f
7 OJ
p(
Building ./L'J�_
O
] 1 have and will maintain Worker's Compensation Insurance, as required by Section 3700 of
/
%�j
Seismic
the Labor Code, for the performance of the work for which this permit is Issued. My Worker's
Compena on Insurance carrier and Policy number are:
Total
Carrie" /o7" � �n r � Policy N1,&k
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.I]
(This section need not be completed If the permit Is for one hundred doll gfy (y]p0�o sJ
1
O Sy, T^ O
b .
l D
certify that In the pedormence of the work for which this permit IS Issue s l n t emplay
any person In any manner so as to become subject to the Workers' ComparestlGn Laws of Cell.
All roofs shall be inspected prior to any roofing material being
fornia. r
2 9 �� D
installed. If a roof is installed without first obtaining an
Date Applicant APR
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It, after making this Certificate of Exemption, you should become
'subject to the Workers' Compensation provisions of the Labor Cotle, y .lp4 it forth ilp EoRgln v
with LII T V
Applicant understands and will comply with all non point
such provisions or this permit shall be doomed 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.
spectlon purposes.
(We) agree to save, Indemnity and keep harmless the City at Cupertino against liabilities,
judgment$ costa and expenses which may In any way accrue against said Cly In consequence
of the greming of @fs permit.
SIGNATURE OF APPLI NT DATE
PFE-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-