R 4821 PE
APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 4821
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-9228 PERMIT EXPIRES IF WORK IS NOT STARTED
'
WITHIN DAYS PERMIT ISSUANCE OR
WI DANSS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWN R's HAZARDOUS FIRE AREA
NAME��4C�� 1iL VES ❑ If yes—I understand that a Class A
f ��[r�XN roof assembly is required.
r NO Ini ial
ADDRESS J L.QS �/tNRIS d/ If EXISTING ROOF COVERING
PHONE
({ NUMBER OF EXISTING COVERINGS
CONTRALTO •S
Poor—
_r / _ _J of9L� TO BE REMOVED TO BE RETAINED
K NAME t�Or [.JfMV�q
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP EXISTING /
PHONE BUILT-UP ROOF [Jf/
NUMBER ASPHALT SHINGLES 11
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license is In lull force and
effect.
WOOD SHINGLES ❑
Cleanse Clara Lia Number
Date Contractor
OTHER(SPECIFY) ❑
OWNER BUILDER DECLARA4Lawt
PROPOSED
hereby affirm that am exempt from the Contractor's Licfollowing reason.(Sec.70315,BImprove entl Profeolish,or rep Code: Any city or ullao a permit to
constapplic ntqalter,Improve,to file si ned st any e,prileorequiresthe BUILT-UP ROOF
applicantforsuch permit to IIIe aelhapt statement thathe lith1 the Drwofthe
of the Contractor's License Law(Chapter h(commencing withDfor the 3 of theBusinessexempio antl Prolotion of Code)or that hs la exempt Ihereile for the alleged ASPHALTSHINGLE$
exemption.Any vloletlon of Section 7031.$by enyepllcame 1ts the applicant to
a civil penalty of not more than live hundred3l larr(S ❑
❑1,as owner of the property,or my analp{� e-it esthair sole compensation,will do WOOD SHAKES
the work,end the structure le not Intentletlbr Ner 0 (Sec.7044,Business and Profes-
slonsCode:The Contractors License Le do lytoanowner ofproperty who builds or WOOD SHINGLES
Improves thereon,and who does such w.J�hl If ori rough his own employees,provided that ❑
such Improvements are not Intended or offeL2d V .If,however,the building or Improvement
Is sold within one year of completion,the owngrr;bWlder will have the burden of proving that he did OTHER(SPECIFY) El
build or Improve for purpose of sale.).
❑1,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.
applytoan ownerofpropar who bullds or Improves thereon,and who contracts for such projects
with a contractor(a)III pur yant to the Contractors Licence Law.
❑I am mpt under ,B&P.C.for this reason PROVIDE MFGR. INSTALLATION SPECS.
OwnerDate APPLICATION DATE VALUATION PERMIT FEE
W—UMITACOMVENSATION DECLARATION
I h y affirm under penalty of perjuryone of the following declaration: [�9
❑I have and will maintain a Certificate or Consent to self-msure for Worker's Compensation, BOIIdIn
,! as,provided for by Section 3700 of the Labor Code,for the performance of the work for which this g
permit is Issued. Rpn^
/AR Seismic
EJI have and will maintain Worker's Compensation Insurance,as required by Section 3700 of JJ�I
1996
-the Labor Code,for the performance of the work for which this permit Is issued.My Worker's n Total
Compensation Insurance carrier and Policy number are; Vi)b
z carrier Policy No. V "'PERMITyAUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.I]
(This section need not be completed If 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 emplay
any person In any manner so as to become subject to the Workers'Compensation Laws of Cas• All roofs shall be inspected prior to any roofing material being
Iornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTsubject ICE TO to the Workers'Com efnseteon provisions ofthe/1cate of Laborr Code,pilon,you should become Applicant understands and will comply with all non point
with ouch provisions or this permit sharbe deemed revoked f°U must forthwith comply source regulations. p y
I certify that I have read this application and state that the above information is correct.)agree
to comply with all city and county ordinances and state laws relating to building construction,and All r f Coverings o be IdSS"C"or better.
hereby authorize representatives,of this city to enter upon the above-mentioned property for in.
epectlon purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against Ilablllllea, —y(/
ludgma'te,coats entl expenses which may In any way accrue against said City In consequence
of he granting of a pemilt. RE F APP CANT 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