R 4739 r
PERMIT R_ 4739
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 160 DAYS OF PERMIT ISSUANCE OR
,• 190 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
-421 7 A0?/AJ /•• 4'. l L_ RESIDENTI /
RCIAL OTHER
OWNERSHAZARDOUS FIRE AREA
d . VES% It yes—I understand that a C C69A
NAME ` `' NO roof assembly is required.
Initia I.C.B.O.
ADDRESS—C2 7 eA41LV&!/V EXISTING ROOF COVERING
PHONE
NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S
�• TO BE REMOVED___L__TO BE RETAINED
NAME—
ADDRESS
AME ADDRESS TYPE OF ROOF COVERING
CITY B ZIP
EXISTING
PHONE r BUILT-UP ROOF
LICENSE
NUMBER ' �� f ASPHALT SHINGLES ❑ v.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that em si licensed under Professions
loss of Chapter p(commencing calif Sectionand WOOD SHAKES
7000)of Dlvlalon ol'ihe Business and Profeealone Cotla,and my license le In full force entl
effect. i� WOOD SHINGLES B ElLicense Close Lic.Number
n
OTHER ( 5'//}'SPECO
Date— / Contractor N 3 '99 fi
OWNER-BUILDER DE LAR ON PROPOSED C/
hereby elilrm that I em exempt from the Contractor's enae Law for the following reason.
(Sac.7031.5,Business and Professions Code: Any cl r county which raqulrea a permit to (Jr'
conetrucL sitar.Improve,demolish,or repair any struct prior to lie Issuance,also requires the BUILT-UP ROOF
applicant icer such permit to IIIe a signed statement th he le Ilceneetl pursuant to the provisions
of the Contractors Uconse Lew(Chapter p(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
e civil penalty of not more than five hundred dollars($500).):
❑I,as owner at 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 Proles- �
alone Code:The Contractors License Law does nal 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
letbuild or
completion,the have the burden of proving that he did OTHER(SPECIFY)
not bull or Improve loo purpose crisis.). '
❑I,as owner of the property,em exclusive ontmcting with licensed contractors to construct ^� b i
the project(See.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO._ O6
.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 I INSTALLATION SPECS.
❑1 am exempt under Sec. ,D&P.C.for this reason
Owner pate
WORKER'S COMPENSATION DECLARATION APPLICATION DATEI VALUATION PERMIT FEE
I hereby affirm under penalty,of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to self-Insure far Worker's Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this g
permit Is leauetl. / Seismic
❑ have a will maintain Worker's CompensetlI surence,ae required by Section 3700 of j /j�
It Labor for the rmance of the work icer hl<h ihle permll le Issued.My Workers i Z
an to Insure tiler end cy u r re: Total
Gerrie WORKERS'
OO'�
ERM;
TAUTHORIZATION DATE
CERTIFICATE OF FROM
MPTION FROM WOflKERS'
COMPENSATION INSURANCE N.00
(This section need not be completed If the permit Is for one hundred dollars($100)or law.)
I certify that in the performance of the work for which this permit Is Issued,I shall not employ
any person In any manner as as to become subject to the Workers'Compensation Laws of Cali. All roof,shall be inspected 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.
ou
subject I.the Workers'CompeCE TO APPLICANT: nsation provisionafter makints of the Labor Code,yolu Certificate of onmust fo thwllthbecome comply Applica nden tends and will comply with all non point
with such provisions or this permit shapthe deemed revoked, sour regulatlo S4be
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 /Alloof COV m sss °O er.
hereby authorlxe representatives of this city to enter upon the above-mentioned property far In-
spection purposes.
(We)agree to save,Indemnify antl keep harmless the City of Cupertino agalnet(we)agree to save, antl keep harmless the city o Cupertino llebwneajudgments,costa antl expenses which may In any way accrue against said City In consequenceof the gmmInp of this permit. N F ANT 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
OFFICF COPV