R 4949 PERMIT
APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 4949
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN DAYS OF PERMIT ISSUANCE OR
180 WITHIN FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL 'OTHER
OWNER'S - HAZARDOUS FIRE AREA
i//Zw � z //� VES ❑ Ifye ass mbly is
that. Class A
NAME— / L�LJ///1J�/ `llc�/�,/�1/ q,cjff/,c�.p NO iropf assembly is requirIntial I.C.B.O.If
ADDRESS 13c'V �ia 'P Ar/��/•r 7 Y//o(a'- e' EXISTING ROOF COVERING
PHONE` NUMBER OF EXISTING COVERINGS
CONTRACTO 'S�r
NAME [i TO BE REMOVED � TO BE RETAINED
ADOREss _777R TYPE OF ROOF COVERING
clTv a zIP / :D o�
EXISTING
PHONE 'YDS-P'aa-69G o BUILT-UP ROOF
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I 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 Code,and my license Is In lull force and
effect.
WOOD SHINGLES ❑
License Class Lic.Number
Date Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATI PROPOSED
I hereby affirm that I am exempt from the Contractor's Licen L w for the following reason.
(Sec.7031.5,Business and Professions Cotle: Any city or cou which requires a permit to
construct,alter.Improve,demolish,or repair any structure,prior to i Issuance,also requires theBUILT-UP ROOF
applicant for such permit to IIIA a Signed statement that he Is license rsuant to the provisions
of the Contractors License Law(Chapter g(commencing with Seri n of Division 3 of the
Business and Professions Code)or that he is exempt theretrryip - the for the alleged ASPHALT SHINGLES ❑
exemption.Any violation of Section 7031.5 by any applicant fol It Our ct the applicant to
e civil penalty of not more than five hundred dollars($ )&.I" —
❑I,as owner of the property,or my employeesw e8 t 'co-pen6e99tion,wllldo WOOD SHAKES ❑
the work,and the structure Is not Intended ora erird Mr s N 4,Bus10Nfano Profen
alone Code:The Contractor's License Law tl not apply to of property who builds or WOOD SHINGLES
Improves thereon,and who tloes such work' Imaelf or ou M is own employees,provided that ❑
such ImDrovementa are
not Intended os ed for sal w$ver;the bullong or Improvement
Is sold within one year of compleflogvl own, ILu l�avethe burden of proving that he did OTHER(SPECIFY) ❑
not build or improve for purpose at'" \1�
❑I,as owner of the property,am flxclu tracting with licensed contractors to construct
the project(Sec.7044,Business and;r essloRs ode:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO.
Sap to an owner of property who bull s or Improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B$P.C.for this.Seen
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: f
❑1 have and will maintain a Certificate of Consent to sell-Insure for Workers Compensation, r�� i Building
1`
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this N �GO
r, permit is issued. 18 19g SeiamiD —mss+
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of J�7
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's y
41
Comperm//,a�I!!UI,,on 1 surance ar�rle/r/.and Policy number are: U,- L't."L Total
Carrier"' rj!✓* Policy No. �Gc—�c/� �i V'2 PERMIT AUTHORIZAT DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.[
(This section need not be completed It the permit Is for one hundred dollars($100)or leas.)
1 certify that in the performance of the work for which this permit Is Issued,I shall not employ
any person In any manner so as to become subject to the Workere'Compensation Laws of Call- All roofs shall a Inspected prior to any ro fin m aria g
fornix' installed. if a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE APPLICANT: after makbecome
subject to theOWorrkers'Compensation provisionis of thel1Labor Code,cate you mustof Exemtion, ufo thwlitlh comply Applicant understands and will comply with all non point
with such provisions or this permit shalGbe deemed revoked. source regulations.
I certify that l have read this application and state that the above Information is correct.I agree V
to comply with all city antl county ordinances antl state laws relating to building construction,antl All r0ato be class "or better,
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spectlon purposes.
We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities
' oftlge granShiating of this pePmlt.enses which may In any way accrue against said City In consequence SI 'URE OF APPLICANT 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