R-4887 PERMIT
APPLICATION FOR
CITY OF CUPERTINO NUMB R R 48
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
•
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
WI1W DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS ///�
/V� "RE,z Pavle� RESIDENTIAL COMMERCIAL OTHER
OWNER'S Ali
� /'�� HAZARDOUS FIRE AREA
NAME rm x✓1 ,Tnere�cc- YES ❑ It Imblyfaantlthat. ClassA
root assembly is and that
' �� •7`i NO ,� Initial I.C.B.O.#.
ADDRESS `'') jjJll EXISTING ROOF COVERING
PHONE / NUMBER OF EXISTING COV INGS
CONTRA OR'S. — x
1rJ TO BE REMOVED TO BE RETAINED,
NAME
ADDRESS G TYPE OF ROOF COVERING
CIN 8 ZIP V
-14 4 O EXISTING
PHONE BUILT-UP ROOF ❑
LICENSE !r^,,
NUMBER W ASPHALT SHINGLE ❑
LICENSED CONTRACTORS DECLARATION
Hereby inion that em licensed under Professions
of Chapter 9(commencing with Section WOOD SHAKES
]000)of Division 3 0l the Business and Prolesaions Code,and my license is In lull force and
effect' WOOD SHINGLES
Licen I ss Ic.Number
OTHER(SPECIP)4 E]Dale Contractor D
OWNER-BUILDER DECLARATION pROPOSEDp
I hereby affirm that I.am exempt from the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to �+ w_
construct,alter,improve,demolish,or repair any structure,prior to Its issuance,also requires the BU1000P'F{NOF y,, Elapplicant for such permit to fila a signed statement that he Is licensed pursuant to the provisions !/
• of the Contractors License Law(Chapter 9(commencing with Section]000)of Dlvl (
slon 3 of the , $.-
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHIN L'@Sr1A� ❑
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to rYo
a civil penalty of not more than five hundred dollars($500).): WOOD SHAKES 01,as owner of the property,or my employees with wages as their sole compensation,will do ❑
the work,and the structure is not intended or offered for sale(Sec.7044,Business and Profes.
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES '
Improve$thereon,and who does such work himself or through his own employees,provided that ❑
such Improvements are not Intended or offered for sale.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)
not build or Improve for purpose of sale.).
01,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 Law does not PROVIDE I.C.B.O.REPORT NO.'T�
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 Lew. PROVIDE MFGR.INSTALLATION SPECS.
01 am exempt under Sec. ,B$P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following suref r Wo ^�
have and will maintain 37 a Certificate of Consent to self-Insure for Worker's Compensation, / ■ BUlldln
as par is for by Section 3]00 of Labor Code,for the performance of work for which this /rI/J
p rml Issued. ^
have and will maintain Workers Compensation Insurance,as required by Section 3700 of /� F/.}//I SOISRIIC
e bar Code,for the performance of the ork for which this permit is Issued.My Workers 2
campsn�a�'kjQ�r//In�/urj?/!]c/e carr tl Poll mbar are: Total
Carrler�/r$/$nti cY Policy ro�bL]/�7`Q p 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 less.) -
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 roots shall Inspected prior to any roofing material being
fornla, installed. If a roof is installed without first obtaining an
Dale Applicant inspection,I agree to remove all new materials for inspection.
subje�io�a APPLICANT.
o e�eCOompeose o provisions of theicate of Laborr Coca Exemption,
mustforthwithitbecome
Comply Applicant understands and will comply with all non point
with such provisions or this permit shalcbe deemed 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 consbucticil roof covering be class"C"ortbetter.
hereby authorize representatives of this city to anter upon the above-mantionetl property for in-
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may In any way accrue against said City in consequence
spection purposes.
of me granting of this permit. IGNATU 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 _