R 4850 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 4850
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN DAYS PERMIT ISSUANCE OR
/ WI DAYSS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
76.3 J S�RaDI✓ H/LL L/ +�
�.�� RESIDENTIAL !!!!� COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES El
If yes—I understand that a Class A
NAME Mrd' S- I-ltao',.Iroof assembly is required.
NO Initial I.C.B.O.N
ADDRESS ✓ EXISTING ROOF COVERING
PHONE Z S—2 — O NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME u .�.v.�eY G TO BE REMOVED TO BE RETAINED
ADDRESS fl� COVERING
CITY&ZIP- _S�c2Ll 40�Ql0 EXISTING
PHONE BUILT-UP ROOF - ❑
LICENSE 6'6 6 ASPHALT SHINGLES
NUMBER ❑
LICENSED CONTRACTORS DECLARATION C7
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES !/
7000)of Division 3 of the Business and Professions Code,.and my license Is In full force and
effect.
License Class � Lie.Number6 6
WOOD SHINGLES
Date CP— 7— contractor L�� OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am 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 71�I
construct,alter,Improve,demolish,or repalrany structure,prior to Its issuance,also requires the BUILT-UP ROOF l( UG "2 Zq99 6
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Lew(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professlons,Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES "r- L
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of not more than rive hundred dollars($500).): q v
❑I,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(Sec.7044,Business and Profes-
sions Code:The Contractor's 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 ❑
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.).
❑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 Contractor's License Law, PROVIDE MFGR.INSTALLATION SPECS.
E]I am exempt under Sec. ,B&P.C.for this reason
Owner oats
WORKER'S COMPENSATION DECLARATION APPLICATION DATEI VALUATION PERMIT FEF.
I hereby affirm under penalty of perjury one of the following declaration: -
❑Ihaveantl willSection 3700
of the
ate bor Consent theperInsure forWorker's Compensation, D�1�� �� y `��,,,^ Bui din
aermiti Is Mr by Section 3700 of the Labor Code,for the performance at the work for which this C/' i 7 j Jr
permit is Issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of 00Seismic
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's
Compensation insurance carrier and Policy number are: .q Total
Carrier 0*7,0 -'f� Policy No. '9/619 /
PERMIT AUT TE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE hi
(This section need not be completed If the permit Is for one hundred dollars($100)or lees.)
I certify that In the performance al the work for which this permit Is Issued,I shall not employ
any person In any manner so as to become subject to the Workers'Compensetlon Laws of Cell. All roots S al inspected prior to any roofi m terial bei g
rorne. installed. f a roof is installed without first obtaining an
Data '� -�'- pplicant Cti--L _ inspectionj agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,alter making this Certificate of Exemption,ifli should become Applicant understands and will comply
subject to the Workers'Compensetlon provisions of the Labor Code,you must forthwith comply pP ply with all non point
with such provisions or this permit shall be deemed revoked. - source regulations. ,.
I certify that I have read 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,
A -1?— 6
judgments,costs and expenses which,may In any way accrue against said City In consequence
of the granting of this permit. SIGNATURE OF APPLICA 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 J