R-4724•
•
�- OFFICE COPY
PERMIT R_ 4724
FOR CITY OF CUPERTINO NUMBER
.APPLICATION
INSPECTION DIVISION PERMITEXPIRATION
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
10120 Pasadena Avenue
XX
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA -
YES ❑ If yes— I understand that a Class A
NAME PAPP
roof assembly is required.
NO Initial LC.B.O. q
same
EXISTING ROOF COVERING
ADDRESS
/
PHONE 408-253-7351
NUMBER OF EXISTING COVERINGS
-
CONTRACTOR'S
-
TO BE REMOVED TO BE RETAINED
NAME Heritage Roofing Inc.
TYPE OF ROOF COVERING
ADDRESS
CITYBZIP 3987 let St "Pit T ivormnrp CA 94990
EXISTING
PHONE 510-447-7508
BUILT-UP ROOF ❑
LICENSE 595748 C39
NUMBER
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B (commencing with Section
WOOD SHAKES ❑X
7000) Of Division 3 Of the Business and Professions Code, and my license is In full force and
affect'
WOOD SHINGLES ❑ �/
License Claes C39 Lic.Number 595748
`
OTHER (SPECIFY) ❑
8/18/97 Steve Dunn
Date Contractor
P A
PROPOSED
OWNER -BUILDER DECLARATION
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 dry or county which requires a permit to
construct, alter, improve, demolish, or repair any structure, prior to Its Issuance, also requires the
AUG 19
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
BUILT-UP ROOF 1�0`9
of the Contractor's License Law (Chapter B (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
nn
ASPHALT SHINOII S Uh �urtN
exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
rifVO
a civil penalty of not more than live hundred dollars ($500)):
WOOD SHAKES
❑I, 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 ❑
Improves 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 bulltling or Improvement
to sold within one year of completion, the owner -builder will have the burden of proving that he tlm
OTHER (SPECIFY) ❑
not build Or Improve for purpose of sale.).
❑ 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 Low 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 contractogs) licensed pursuant to the Contractor's License Lew.
PROVIDE MFGR. INSTALLATION SPECS.
❑ I em exempt under Sec. a 8 P. C. for this reason
Owner Date
APPLICATION DATE
VALUATION
PERMIT F
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty OI perjury one of the following declaration:
❑ I have and will maintain a Certificate of Consent to sell -Insure for Worker's Compensation,
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
8/97
12200.00
BUlldln
permit Is Issued.
Seismic
X I have and will maintain Worker's Compensation Insurance, as required by Section 3700 of
the Labor Cotle, for the performance of the work for which this permit Is Issued. My Workers
Total
Compensation Insurance center and Policy number are:
Carrier State Fund Policy No. 285-97 664
PERMIT AUTHORIZATION
DATE
CERrIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.I]
(This Section need not be completed It the permit le for ne hunareCap llera ($100) or lass.)
I certify that In the performance Of the work for whlo a permit le Issue shell not employ
any person in any manner so as to become Subject to Workers' Comp ion Lawe of call-
All roofs ha I be inspected prior to any roofing material being
totals.
installed. If a roof is installed without first obtaining an
Date 8/'$/97 Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If, after millZing this Certificate of Exemption, you should become
Applicant understands and will comply with all non point
pP P Y P
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
with Such provlslons Or this permit $hall be deemed revoked.
Source re rations.
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 Brings to blass "C" or better.
hereby authorize representatives of this city t0 anter upon the above-mentioned property for in.
hrebon purposes.
(We) agree to save. Indemnity and keep harmless the City of Cupertino against liabilities,
judgments, costs and expenses which may In any way accrue against said City In consequence
of the granting of this 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