R 4980 PERMIT R_ 4980
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
•
WITHIN PERMIT ISSUANCE OR
WI DANSS FROM
LAST CALLED INSPECTION.
BUILDING ADDRESS
10061 Pkw
lci 01V7• /
RESIDENTIAL ✓. COMMERCIAL OTHER
—
OWNER'S
HAZARDOUS FIRE AREA
°� I la�'L V �Q I a.r NES ❑ If yes—I understand that a Class A
NAME
roof assembly is required.
/ / r_ NO Initial I.C.B.O.#
P
ADDRESS- GyO0 ( f (apt,✓ Lam.p (� ' EXISTING ROOF C
/ 7 OVERING
PHONE % J �3 - 1 NUMBER OF EXISTING COVERINGS `
CONTRACTOR'S L,[
NAME— W5 f J�I�. TO BE REMOVED TO BE RETAINED
ADDRESS5869 w� / L _/ P TYPE OF ROOF COVERING
CITY&ZIP- S161 T�t,Ol- GL
`moo /yEXISTING
PHONE 'f`/O "'��p ` �� BUILT-UP ROOF El
LICENSE
NUMBER Z p ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 em licensed under provisions of Chapter g(commencing With Section WOOD SHAKES .El
of Division 3 of the Business and Professions Code,and my license is In lull force and
effect.
OI WOOD SHINGLES
LicenseClaw C 1 LIc.Number
Dare Contractor ❑ /� / /tG/-
led[ iC7 OTHER(SPECIFY) Elt/21l0.✓0. f f
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors License Law 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
f the Contractor's License Lew(Chapter a(commencing with Section 7000)of Division 3 of the
usiness 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
civil penalty of not more than five hundred dollars($500).):
C]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 Profes.
sions Code:The Contractors 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 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.).
Ol,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Law 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 contractor(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B&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: // fj�f {/
❑I have and will maintain a Certificate of Consent to sell-insure for Workers Compensation, /q o Building
as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which this F{I Q r g
P
avit le lssuetl. Seismic
e 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 Worker's Ub 22 Total
Compermation Insurancercarrier en�dfPolicy number are; �{
Carrier-S�R('t r�hr/� Policy NO. `� l.'/fyLpERMITAU ORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
s COMPENSATION INSURANCE N.C.p • tet!r lr vu -7-^L
(This section need not be completed If the permit Is for one hundred dollars($100)or leas.)
I certify that In the performance of the work for which this permit Is Issued I shall not employ
any person In any manner so as to become subject to the Workers'compensation Laws of call. All roofs shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date �—LZ� `� Applicant '"/ "V t� L' inspection,I agree to remove all new materials for inspection.
NOTICE TO subject to the Worrkerss'Compefnsatlon provisions after softhelcate of Laborr Code,you must
should become Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked You must farlhwith Comply
source regulations.
certify that ihave redtlthis ouny ordinancion es and
sterethat the above Information Is correct. agree
to hereby authorwith ize
cityrep and tabes of this ce9 and ter upon
thel ting above-mentioned
property
and All root coverings to be class"C"or better.
herebyyn purposes.repressntmivae of ihle city to enter upon the ebovd-mentioned property ror In-
ap(We) purposes , r r
(We)agree s neve,Indemnify and keep harmless the Cly of Cupertino y In con liabilities.
ence 'I�f,.'"on(V��.�/
judgments,costs and expanses which may In any waY acc.ue against ealtl dy In consequence
of the granting Of thl$permit. rbIGNATURE 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