R 4953 PERMIT
CITY OF CUPERTINO NUMBER R_ 4953
APPLICATION FOR INSPECTION DIVISION
PERMIT EXPIRATION
REROOF PERMIT
(408),777-3228 PERMIT EXPIRES IF WORK IS NOT STARTER
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
' 1B0 RAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
?�
OC7� 1 ✓ K•� �C_�1 1J�. 1-Jlc_'U� �SQIy RESIDENTIAL COMMERCIAL OTHER -
OWNER'S HAZARDOUS FIRE AREA
,;11 A `p r„0.,� i I ,\, 1 YES [XI If yes—I understand that a Class A
NAME 'vt. l%V l VyV roof assembly is required.
^ NO ❑ Inidal—Ce-1 I.C.B.O.#
ADDRESSd �S EXISTING ROOF COVERING
PHONE I—I ` OY 255- D9 36 NUMBER OF EXISTING COVERINGS I
CONTRAtC�T^ORn'5�� (',�,,,.,(� I
NAME I`�I I:x N�o" F�(XJT TO BE REMOVED 70 BE RETAINED
x ADDRESSa q f..l I,� TYPE OF ROOF COVERING
t CITY&ZIP .JLv"
OQ) u1ll-OQ33
EXISTING
PHONE 1 1 BUILT-UP ROOF ❑
NUMBER . 5aO5"N ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
hereby iaffirmnion that I am Business
ender Professions
of Chapter 9(commenting with Section WOOD SHAKES
7000)of Division 3 of.the Buslneee end Pr0leaslone Cade,and my license Is In lull lona and
effect. U
License Claes Llc.Number 5aWOOD SHINGLES Ela5� 1
Data Contractor
MmiYt M 1HA +R Cc,lic., OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATIO PROPOSED
hereby affirm that I am exempt from the Contractor's License w for the following reason.
IS
7031.5,Business and Professions Code: Any city or count hich r it,I ae a permit to
construct,alter.Improve,demolish,or repair any structure,prior to Its b and also requires the BUILT-UP ROOF JUIV q[• ❑
applicant for such permit to file a sgned
at
that Is 11gedea rsuan to the provisions rV ,4 d fin^
' of the Contractor's License Law(Chapter B(command t Division 3 of the JaL(Yl
Business and Professions Code)or that he le exempt M r t sale for the alleged ASPHALT SHINGLES
exemption.Any violatlon of Section 7031.5 by any appy fo r subjects the applicant to • vp
a CIAI penalty of not more than five hundred a011 4r($ f+l. -
❑I,asowner ofthe property,ormyempl h gas sit sole compensation,will do WOOD SHAKES
the work,and the structure Is not Intended I a r sal do.7044,Business and Profes.
stone Cotle:The Contractor's Licen6e Le do 1 e plyl�en owner of property who builds or WOOD SHINGLES '� ��NJ..., /1
Improves thereon,entl wha Ooee such k orroughhis own employees.provided that I Lbtr
such Improvements are not Intended o ed to 11,II,however,the building or Improvement
Is sold within one year of completion,the der 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 Contractor's 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 MFG R. INSTALLATION$PFOB.
❑(am exempt under Sec. ,B 8 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:
I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, BDldln
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this / I_ g
r permit Is C1leand YY"�/ Qj�(oe� Seismic � rl
I have entl will maintain Worker's Compensation Insurance,as required by Section 3700 of I `r
_the Labor Code,for the performance of the work for which this permit is Issued.My Worker's Total f
Compo lion Ineura` e c�a'r^ne'�and Policy number are:
t Carrier s�/�'L`✓`� Policy 1402 �(0 06 0 PERMIT AUTHOR17ATIO DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.I]
(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.hall not employ
any person In any manner so as to become subject to the Workars'Compensation Laws of Cell- All roofs shall be inspected prior f an roofing ateri I being
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making thle Certificate of Exemption,you should become
subject to the Workers'Compensation provisions of the Labor Cotle,you must forthwith comply Applicant understands and will comply with all.non point
with such provision or this permit ahafte doomed revoked. source regulations.
I certify that I have read this application and slate that the above Information Is correct.I agree
to comply with all city and county ordinances and stale laws relating to building construction,and All roof coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
apache)purposes. ^r
(We)agree to Rave,indemnify and keep ha,way the City al Cupertino against IIabIIence
of the gran,costa end permit. s which may In any way accrue egalnsl said City in consequence
' of the granting of this permit. SIGNATOR O APPLICANT DA
PRE-INSPECTION: PLYWOOD: -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