R-4658•
•
•
OFFICE COPY
PERMIT R_ 4658
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
1B0 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
3 `4-e
v e 0 �_
RESIDENTIAL— CIAL OTHER
Ow R'sDo
HAZARDOUS FIRE AREA
t-(
YES ❑ 1 yes - I understand that a Class A
NAME-- 1
ool assembly is required.
NO Initial I.C.B.O. M
EXISTING ROOF COVERING
ADDRESS GC
NUMBER OF EXISTING COVERINGS
-' 2— 2
2--S
PHONE
CONTRACTOR'S.�
'--
NAME 8
TO BE REMOVED TO BE RETAINED
ADDRESSTYPE
tl(c74 A
OF ROOF COVERING
CITY 8 ZIP
EXISTING
7
PHONE ��^�J Q L
BUILT-UP ROOF ❑ ,
LICENSE
NUMBER q6
ASPHALT SHINGLES
'
LICENSED CT ACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B (commencing with Section
WOOD SHAKES ❑
7000) of Division 3 of the Business and Professions Cade nd my license is in full force a d
effect'
WOOD SHINGLES
ElDate
License lass Lic. Number
2— ��
OTHER (SPECIFY) El
contactor
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 Elapplicant
for such permit file a signed statement that
Lich pursuant to the provisions
pursuant
ish Sect
of Ne Contractor's License Lew (Chapter a (commencing with Section ) of Division 3 of the
g o
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 five hundred dollars (8500).):
WOOD SHAKES
I, as owner of the property, or my employees with wages as their sole compensation, will do
E]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 E]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-bulider will have the burden of proving that he did
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 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 Contractor's License Law.
PROVIDE MFGR. INSTALLATION SPECS.
❑ t am exempt untler Sec. ,B 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:
-11 have and will maintain a Certificate of Consent to self -insure for Worker's Compensation,
as lot by Section 3700 of the Labor Code, for the performance of the work for which this
/r,
Building_
provided
permit Is issued.
`y Q
Za°-
Seismic
1 have and will maintain Worker's Compensation Insurance, as required by Section 3700 of
the Labor Code, for the performance of the work for which this permit Is Issued. My Worker's
o"rcy
�Ir
NOVTotal
Compensate ns ones carrier a"n num are: C.{�
Y r r. PER H W THORIZATION
DATE
Policy No. /C�l
.Carrier
E TIF ATE OF EXEMPTION FROM WORKERS'
IN C.p
6,Or
COMPENSATION INSURANCE
f rA 1
(This section need not be completed it 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 Call-
All roofs shall bbinspected prior to any roofing material being
fornia.
installed. If a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
Applicant understands and will comply with all non point
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
with such provisions or this permit shall be 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 construction. and
All Verings to Class "C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes.
(We) agree 10 save, Indemnify and keep harmless the City of Cuperlino against liabilities,
f
judgments, costs and expanses which may in any way accrue against avid Ciry in tonsequance
SI RF OF APPLICAMT
of the granting of this permit.
VAIE
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
M
Cupertino
I understand and comply with Section 1210-A of the Uniform Building Code.
Section 1210-A requires when repairs to a single family dwelling exceed $1,000, a smoke
detector will be installed, mounted on the ceiling or wall in each sleeping room and at a
point centrally located in the corridor or area giving access to room used for sleeping
purposes. If existing smoke detectors comply, no new detector shall be required.
• I understand the above requirement and certify that we now have smoke detectors
installed that do comply. j
ADDRESS: v �` k� -ee I4 K
PERMIT NUMBER:
HOMEOWNERS SIGNATURE:
DATE: �— Z 1 — 5 5
winword/smkdel
Pnnted on Recycled Riper