R-4538 APPLICATION FOR CITY OF CUPER I NO
NUMB PERMIR R- 4538
INS CTION DIVISION PERMIT EXPIRATION
REROOF PERMIT 8)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN IN DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS /
RESIDENTIAL ✓ COMMERCIAL OTHER
OW R's HAZARDOUS FIRE AREA
' I ' YES ❑ It yes—I understand that a Class A
NA E Cn /;�: root assembly is required:
C, / NO Initial I.C.B.O.k
ADORES 5 2 ( - 1' ll EXISTING ROOF COVERING -
NUMBER OF EXISTING COVERINGS
PHONE
CONTRACTOR'S
NAME J ✓(i �H d (.� 'zl cj—� t-✓` TO BE REMOVED Q TO BE RETAINED
ADDRESS
TYPE OF ROOF COVERING
CITYazIP /�a �f� �`� EXISTING
PHONE 4cJ AR-6 — BUILT-UP ROOF ❑
LICENSE
NUMBER 3Ct 47 ASPHALT SHINGLES [�
LICENSED CONTRA 0 S DECLARATION 1
hereby affirm that I em licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES El
00)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect' WOOD SHINGLES ❑
License Class Lip.Number
Date Contractor OTHER (SPECIFY) ❑
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,shot,Improve,demolish,or repair any sruclure,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 Contractors License Law(Chapter g(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 five hundred dollars($500).): SHAKES
WOOD
I]I,as owner of the property,or my employees with wages as their sale 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 bullds or ODD SHINGLES ElImproves 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 diOTHER(SPECIFY) El
build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to consiru
the project(Sec,7044,Business and Professions Code:The Contractor's License Law dose 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.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Date APP ICATIO_N DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: Or
011 /6V
_ ®
❑I have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, V 7O Building
as provided lot by Section 37W of the Labor Code,for the performance of the work for which this
permit is issued. / CA _V Seismic
I]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 G
Compensation Insurance carrier and Policy number are: �Fti 99 Total
Carrier S T� (+' C(h1A 16 Policy No. ;rZ �' if�U1fiT PEJ5MITAUTHORIZATIO DATE
CERTIFICATE JF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.[] �}s
(This section need not be completed If the permit Is for one hundred dollars($100)or less.) Gi/s
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' mpensatlon Laws o an- All rooff shall be inspected prior to any roofing mat6firial being
fornia. L installed. If a roof is installed without first obtaining an
Date � a?'�/� Applicant inspection,I agree to remove all new materials for inspection.
NOT CE TO subject t.the Workers'Compenseteon provisions of thlellcateLabor Code,you musuforthwlthbecome
Comply Applicant understands and will comply with ail non point
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 stets laws relating to building construction,and All roof coverings be class"C"or better.
hereby authorize representatives of this City 10 enter upon the above-mentioned property far in. ///��)
apatite)purposes. '• ���
(We)agree to save,expenses
and keep hay a y the City of Cupertino against liabilities. �l!/XU.I[/L
judgments,costs and expenses which may In any way accrue against said Cly In cronsequence
of ma 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY