R 4872 PERMIT R_ 4 8 7 2
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
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S Ca fes,,,,,._ rl4� p 4 HAZARDOUS FIRE AREA
NAME /O /Jm� "JJLLvJ c YES 0 I yes-I understand that a Class A
�-/I ( Y" �M('. . roof assembly is required.
/ _ NO X Initial I.C.B.O.X
ADDRESS hla.s "A", �'.�r7.:Fa-'T-5 '�
EXISTING ROOF COVERING
PHONE — NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAME .
ADDRESS c7 V��i TYPE OF ROOF COVERING
aTvanP �/�� p , EXISTING
PHONE_6u�0�) �l��- ! UILT-UP ROOF ❑
LICENSE
NUMBER �� ASPHALT SHINGLES ❑
LICENSdunderCONTRACTORS DECLARATION -
hereby iaffirmnion that I em usi licensed under Professions
of Chapter 8(commencing with Section OOD SHAKES
7000)of Olvlelon 3 0l the Bualnaee and Proleealons Cotle,and my license Is In lull force and
effect. WO SHI GLES ❑
License Claes -�/ Llc.Number -2r/2
/-/"9OTHER ECIFY
Data r Contractor /1' �✓/ ( ) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Lew for the following reason.
(Sec.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 Contractor's License Lew(Chapter 8(commencing with Section 7000)of Division 3 of the
• Business and Professions Code)or that he Is exempt therefrom and the basis for the shaped ASPHALT SHINGLES ❑
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e all penalty of not more than live hundred dollars($500).):
the❑work,sand the structure er of the plsrty,or my not Intended foyees or ofereith wages as d for sale(Se .their044 compensation,
usiness and'Profee� WOOD SHAKES ❑
alone Code:.The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES •Y•r
Improves thereon,and who does such work himself or through his own employees,provided that ❑ L T /v�
such Improvements are not Intended or offered for sate.If,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER (SPECIFY) I
not build or Improve for purpose of sale.).
01,as owner of the property,em exclusively contracting with licensed contractors to construct �D/J
the project(Sec,7033,Bualnaee end Proleealons Code:The Contractor's License Lew does not PROVIDE I.C.B.O.REPORT 7�
apply to an owner of proper he builds or Improves thereon,and who contracts for such projects
with am
ndo,Sdpursuantto the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I em exempt untler Sec. ,8 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
01 have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, Buildingir3 7
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this / �}� 2 77
oo
permit Is Issued. (T '/7 f O� Seismic
I have end will the pert rmancWorkers f the work
for Insurance,as required Is I by Section 3700 of
the Labor nt i for the performance of cy work for which this permit le leeuetl.My WorkeYa -7 O
Campensatl�o Insurance carrier and Polley number are: Total
Carrier•'n iiH 1/mc. 17-• Policy No, El ld6 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O T
(This section need not be completed it the permit Is for one hundred dollars($100)or leas.) J O A - O z 1_q p.q
I certify that in the performance of the work for which this permit is leeuetl,I shell notgg�p1py IC
any person In any manner so as to become subject to the Workers'Compensation Lawe g"a I All roofs shall be inspected prior to any roofing material being
fornla. installed. If a roof is installed without first obtaining an
Date Applicant action,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certl/Icate of Exemption,you eh a ((cant understands and will com I •with all non
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply 9 p y point
with such provisions or this permit shell be deemed revoked. //�.I((yy /, Source regulations.
1 certify that I have read this application and state that the above Information IVr!dnscWtegbb/1'Ci:r,
to comply with all city and county ordinances and state laws relating to building construction,and wroof coverings to be class"C"or better. ��
hereby authorize representatives of this city to enter upon the above-mentioned property for In
spection purposes / /1
(We)agree to save,Indemnify and keep harmless the City of Cupertino against Ilebllltlea. '-1F
judgments,costs and expenses which may In any way accrue against sold Clty n consequence
• of I a granting of this permit.- SIGNATURE OF AFWPLICANT 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
OFFICE COPY