R 4873 APPLICATION FOR CITY of CUPERTINo
NUMPERBER R- 4873
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
RESIDENTIAL--)LCOMMERCIAL OTHER
OWNER'S / HAZARDOUS FIRE AREA
NAME— �O 621 YES ❑ It yes-l understand that a Class A
— /�/Lvvi n� C'.• root assembly is required
Initial I.C.B.O.q
ADDRESS. &, LE9• ge 0.7� EXISTING ROOF COVERING.
PHONE �� 7� NUMBER OF EXISTING COVERINGS
CONTRACTOR'S 'TO BE REMOVED TO BE RETAINED
/J
NAME—
ADDRESS
AME ���Gyi G ADDRESS �4 p �� l& n s L TYPE OF ROOF COVERING
CITY d zip /Oct �t� 7 EXISTING .
PHONE— �✓`^� — /� �—�� 9 9 BUILT-UP ROOF ❑-
E
NUMBER �� Cy PHALT SHINGLES
❑
NUMBE
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 8(commencing with Section OD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and
effect.
License Claes 14_ �� Llc.Number r�. U WO S GLES ❑
'
( ❑
Date .Contractor OTHERY)
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 0(commencing with Section 7000)of Division 3 of the
• Business and Professions Code)or that he Is 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 live hundred dollars($500).):
Cl 1.as owner of the property,or my employees with wages as their sale compensation,will do WOOD SHAKES ❑
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profen
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑ Lr T•CF_
Improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for sale.It,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)
not build or Improve for purpose x18106.).
0 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 Lew does not PROVIDE I.C.B.O.REPORT NO. CIL 2
apply to an owner of property who builds or improves thereon,and who contracts for such projects
with a cantonal licensed pursuant to the Contractor's LicensecantonalPROVIDE MFGR.INSTALLATION SPECS.
E]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, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this ,/ /^Qn .y �OOo
permit Is issued. /y 770"" c2 / Seismic 9 0
❑I have and will maintain Worker's Compensation Insurance,as required by Section 370001
-the Labor Code,for the performance of the work for which this permit is Issued.My Worker's -� Q/'�
Compenaa on Insurance carrier and Policy number are: Total /:0 CIO
Card . 1 / Policy No.U112,lO lZa L 12-p PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.[]
(This soc•Ilon need not be completed If the permit Is for ane hundred dollars($100)or less.)
P I `
I certify that In the performance of the work for which this permit Is Issued,I shall not employ L 7
any person In any manner so as to become subject to the Workers'Compensation Laws orflsa ,1��(�f{;shall be inspected prior to any rooting material being
Ixrnia. XPR I( �II�d. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
subject to the WorkersICE TO CCompef,after nsation provisionis of theficate of Laborr Code,Exemption,
mustufo forthwith
comply l Applicant understands and will comply with all non point
with such provisions or this permit shalfbe deemed revoked. Source.regulations.
I certify that I have read this application and state that the above Information Is correct.I agree
to hereby uthorizG cityrep and tabes of this city to entet upon thel above-mentioned
edproperty
fand AIIAII roof C be Cl2S5"C"Or better
hereby comply
withall
representatives of thin city to anter upon the sing to building
entlon construction,property for In. ` ,
ep'We' purposes. ( 1
(We)agree to save,Indemnify and keep harmless the City of Cupertino against Ilablllllee, 1
judgmanta,conte and expenses which may In any way accrue against said City In consequence
ofg gmnung of mm permit. 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY