R 4817•
PERMIT
APPLICATION FOR CITY OFCUPERTINO NUMBER R- 4 817
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
Q131.11
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� �� V�U� FOrol�
r
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
c1 lata I
VL
YES [�j If yes — I understand that a Class A
NAME `, .R.0 • A M % i.0 N
J roof assembly is required.
NO ] Initial I.C.B.O. a
(yam
Q. 3qIZUr"Y�o-Y� th
EXISTING ROOF COVERING
ADDRESS J -3 I6
7
PHONE / �O Z
NUMBER OF EXISTING COVERINGS
CONTRACTORS
TO BE REMOVED TO BE RETAINED
NAME , 1 Y2
.6a
ADDRESS
5
TYPE OF ROOF COVERING
CITY & ZIP sV V
EXISTING
/
PHONE _7q�' T Q �--�
BUILT-UP ROOF
LICENSE 6
NUMBER
ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
hereby affirm that I am licensed under provisions of Chapter g (commencing with Section
WOOD SHAKES -� a
700 0) of Division 3 of the Business end Professions Code. and my license le In full force and
Jj
effect.
LicenseClass C— 3 o Number
WOOD SHINGLES lJ
0
W�'I
WAR n
�' � �Q � Ca �
OTHER (SPECIFY) r�
iQ
Date Can to w,�
OWNER -BUILDER DECLARATION
CI)Y/
Ur
I hereby affirm that I am exempt from the Contractors License Law for the following reason.
PROPOSED Vt%r�Cl i IIIVV b
(Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to
construct, alter, Improve, demolish, or repair any structure, 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 Contractor's License Lew (Chapter 8 (commencing with Section 7000) of Division 3 0l 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 live hundred dollars ($500).):
1, the
WOOD SHAKES ❑
E] as owner of property, or my employees with wages as their sole compensation, will do
the work, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Profes-
slons Code: The Contractor's License Law does not apply to an owner of property who builds or
Improves thereon, and who does such work himself or through his own employees, provitletl that
WOOD SHINGLES ❑
such Improvements are not Intended or offered for Bele. If, however, the building or Improvement
Is sold within one year of completion, the ownerbulldor 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 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(s) licensed pursuant to the Contractors License Law.
PROVIDE MFGR. INSTALLATION SPECS.
E]I em exempt under Sec, ,B $ P. C. for this reason
Owner Data
APPLICATION DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
�%�sl—
❑ I have and will maintain a Certificate of Consent to sell -Insure for Worker's Compensation,
BUlldin
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
permit Is Issued.
g
$eISmIC no
❑ 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
Compenstion Insurance Policy
Total
carrier and number are; Q
PERMIT AUT TI
DATE
Carder��A Policy No.f373a !J`
CERTIFICATE OF EXEMPTION FROM WORKERS'
AG
COMPENSATION INSURANCE N00) o
(This section need not be completed If the permit Is for one ($100) or lace.)
irit Is I sued,dollars I
I certify that in the performance of the work for which this t le issued, shell not emptoy
In
All roofs shall be inspected prior to any roofing material being
any person any manner so as to become subject to the rkers' Compensation Laws of Call.
fornix.
installed. If a roof Is installed without first obtaining an
Date; Applica
inspection, I agree to remove all new materials for inspection.
NOTICsubject IOEha WorkereTO CCompenaetlon pmivlelons firilg boto �Cotlemyoiu must forthwith comply become
Applicant un erstands and will comply with all non point
with such provisions or this permit shallIbe tleema yoked.
SOU reg reg Ir
I certify that l have read this applicatlon and state that the above Information Is correct.I agree
to comply with all city and county ordinances and state taws relating to building Construction, and
All roof Ings to be class "C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
directionpurposes.
(We)
(Wel agree tocosts save, Indemnify entl keep harmless the City of Cupertino against Ileblliiles,
judgments, and permit, a welch may In any way accrue against Bald City In consequence
of the granting of this permit.
ngof
IG ATU A PLICANT DATE
PRE -INSPECTION:
PLYWOOD: r.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