R 4792 PERMIT R_ 4 7 9 2
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN DAYS PERMIT ISSUANCE OR
_18WI DAYSS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OW R"11 HAZARDOUS FIRE AREA
J ,(�/1 �/ A. YES ❑ If yes—I understand that a Class A
NA E / `Y1- -A roof assembly is required.
O / N Initial I.C.B.O.tt
ADDRE �rc��� /L- EXISTING ROOF COVERING
PHONE Coos ) 6 ` /—7 0 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S p
NAME' T D IM1.CJO �rJ Co TO BE REMOVED TO BE RETAINED
"ADDFIESScrvazlr ?jCC,O 104P— Co
4-uE P VE
RING
519 N 70 S 7 EXISTING
f' PHONE( O8 ) Z Lk a— 10 f•[- Z BUILT-UP ROOF ❑
LICENSE
NUMBER C-,76)l;2 Z ASPHALT SHINGLES El
LICENSED CONTRACTORS DECLARATION V
Hereby iaffirmnion that em si licensed under Professions
lona of Chapter 9(commencing with Section WOOD SHAKES
7000)of DIVISIon 3 0l the Business and Profesalone Cotla,entl my license Is In lull lone and
enact. 6 Z 2WOOD SHINGLES ❑ S�
License Cl7 Class _3 21 Llc.Number 6 6 . S
Data 1 $ 1 contractor OTHER(SPECIFY) ❑
TOWNER-BUILDER DECLARATION PROPOSED
hereby affirm that I em 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
applicant,alter.Improve,tofilesigned statement
any ntrthat e,prior to pe lseuence,also requires the BUILT-UP ROOF
consirenl for aropermit to Isledemolish,or re air any structure,
he Is licensed to Its pursuant al the Provisions
the
• of the Contrectofa License Lew(Chapter 9(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($500).):
E]1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or allered for sale(Sec.7044,Business and Profea-
aloneCode:The Contractors License Lew does not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,provided that ❑
such Improvements are not Intended or offered for sale.If,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER
not build or Improve for purpose of su le J. (SPECIFY)
❑
❑I,as owner of the property,em exclusively ontmcting with Ilcansed cantrectore to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(a)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS,
C]I em exempt under Sec. ,B$P.C.for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
ra I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to sell-Insure for Workefe Compensation, �� �r O Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this ze /b`.c+fY7
permit Is issued, �! s� v " SBISrr11C
s ❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of 0i'r ^F6
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's r J' o
Compensation Insure ca carrier end Policy number are: Vh Lr w� Total
Carrier S (7 '�UN� Policy No. I42714 _97 PERMITfAUTHORI DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.I] — A,
(This section need not be completed If the permit Is for one hundred dollars($100)or lase.)
I certify that In the performance of the work for which this permit Is Issued,I shall not employ
any portion In any manner so as to become Subject to the Workers'Compensation Laws of Call. All roofs shall be inspected prior to any ro fing mater I b Ing
fornle. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE subjects to then orrkers'C Compensation provchar isions of thelcate of Laborr Code,Exemption,
mustufothwld become
ith comply Applicant understands and will comply with all non point
with such provisions or this permit shell be deemed revoked. Source regulations.
I certify that I have reed 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 roof coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes. .�
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities: -- --
' ludgmenfe,coat°entl expenses which may In any way accrue epelnet said CIN In consequence
of the granting of this permit, Si TURE 0 PP AN- A
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