R 4789 PERMIT R_ 4789
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)7.77-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
A /t kL e – RESIDENTIAL COMMERCIAL OTHER
OWNER's�J� ///]]],,,I,ppp !/` HAZARDOUS FIRE AREA
NAME7xi s /lLy VES ❑ Ryes–embly isrequired. ClassA
roof assembly is required.
Q NO . Initial I.C.B.O.#
'ADDRESS oZa 44 4,f(J -A f 7 -0,k,J `I (1�• EXISTING ROOF COVERING
PHONE aZS2— oe_47 0 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S 1/L� �i D D / ,
N
7 TO BE REMOVED 70 BE RETAINED
NAME
t
ADDRESS --Mil TYPE OF ROOF COVERING
clTvs]1P X75 ��1bl1{�1 f/ d
�J S/2- EXISTING
a PHONE C 2/— 11262S BUILT-UP ROOF ❑
LICENSE
NUMBER a1 ASPHALT SHINGLES f�1CY �j
LICENSED CONTRACTORS DECLARATION
hereby affirm that I am licensed under provisions of Chapter g(commencing with Section WOOD SHAKES
7000)
of Division 3 of the Business and Professions Cotla,and my license Is in lull force and
e
effacWOOD SHINGLES ❑ /�
License Claes Lip.Number
Date Contractor
OTHER(SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from the Contractor's License Law for the following reason.
(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 theBUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor'$License Law(Chapter g(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
a civil penalty of not more than five hundred dollars($5001.):
C]1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure is not intended or offered for sale(See.7044,Business and Profes-
sions Cotle:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,provided that El
such Improvements are not Intended or offered for sale.If,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY)
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Coda:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improve$thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.IN$TALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION - I.«
1 hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, VAD p Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this rrll V
permit Is Issued. (( r�,
[21 have antl will maintain Worker's Compensation Insurance,as required by Section 3700 of WI I I U� L
�r ��� �� S0 V O.0-0 seismic
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's
CompensLejl�on In�sstu�rranceeccarrier nd Policy number are: ) q Ch llh' Total
Carrier 67�4T9 AV A77 Policy No. / 3 O '/ C PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' ot
COMPENSATION INSURANCE N.C.❑
(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 employ
any parson In any manner so as to become subject to the Workers'Compensation Laws of Cell- All roofs shall The Inspected prior to any roofing material being
forma. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOT CE TO become
subject t.the Workers'Compefnsatlon provi,after sIons of the fiLabor Code.cate of Exemption.
mustufo forthwith comply A li ant understands and will comply with all non point
with such provisions or this Parrott ahalQbe deemed revoked. oL', (egUlatlonS.
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 stale laws relating to butd ng construction,antl A Of CO rings tO I S"C"Or better.
hereby authorize representatives of this city to enter upon the above-mentinnetl property for In-
spection purposes. ,S
(We)agree to save,indemnify and keep harmless the City of Cupertino against Ilabilitiea, 314
f(y
judgments,costa and expenses which may In any way accrue against said City in consequence
of me granting of this permit. GNATURE OF APPL419ill 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
OFFICE COPY