R-53840
OFFICE COPY
PERMIT
538-4
APPLICATION FOR CITY OF CUPERTINO NUMBERR_
INSPECTION DIVISION PERMIT EXPIRATION
REROOFPERMIT (408)777.3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1BO DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
,
c-
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE -AREA
r
YES ❑ If yes understand that. Class A
NAME/i Ir �1,- �• 77`''1 J
s
roof assembly Is required.
NO - Initit ial LC.B.O. a
S 4M F
EXISTING ROOF COVERING
ADDRESS
S4'(.7
NUMBER OF EXISTING COVERINGS
PHONE if
CONTRACTO 'S
v / O f •� i1-e;� � ` (�
I��,
NAME Y/,Of Y C/r/
TO BE REMOVED TO BE RETAINED
I
ADDRESSCr r1 IS -rte s Jam,
y
TYPE OF ROOF COVERING
CITY & ZIP l v�J / (.
EXISTING
^
`77 -7SGO
PHONE
BUILT-UP ROOF
CENSE
NUMBER 01 O
ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em Ilcensetl under provisions of Chapter 9 (commencing with Section
WOOD SHAKES ❑
]000) of Division 3 of the Business and Professions Code, and my license le In lull force and
affect.
�c
License Class ` 3 Lid. Number
WOOD SHINGLES ❑
Date Contractor
OTHER (SPECT ❑
PROPOSED
'
OWNER BUILDER DECLARATION
hereby affirm that theam exempt from the Contractor's License Law for the following reason.
(Sec. ]031.5, Business entl 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 Contractors License Law (Chapter 9 (commencing with Section ]000) 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 (SS00).):
1,
WOOD SHAKES ❑
C] as owner of the 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-
sions Code: The Contractor's License Law does not apply to an owner of property who builds or
WOOD SHINGLES El
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, em exclusively contracting with licensed contractors to construct
the project (Sec. 9044, Business and Professions Code: The Contractor's License Law 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 contractors) licensed pursuant to the Contractor's License Law.
PROVIDE MFGR. INSTALLATION SPECS.
❑ 1 am exempt under Sec. ,B & P. C. for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION
PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑ I have and will maintain a Certificate of Consent to self -Insure for Worker's Compensation,
BUIIdin7,9n
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
Is Issued.
permit
OCT 21 OMA
Seismic
Worker's Compensation the workfor Insurance, as required by Section 3700 'of s
❑ have and will the performance
the Labor Code, for the padormence of the work for which this permit Is Issued. My Worker's
Compensation Insurance carrier and Policy number are:
�!
Total
[+ R,
1' /040417
CITY Ur UUPtH I l
O
PERMITAUTHORIZAT N
DTE
Carrier Policy NoS�l__
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.[
O
(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 shall not employ
any person In any manner so as to become subject to the Workers' Compensation Laws of Can-
All roofs shall be inspected prior to an7 roofing starlet being
fornia.
installed. If a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It, after making this Certificate of Exemption, you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
Applicant understands and will comply with all non dint
PP P Y P
with such provisions or this permit shell be deemed revoked.
Source regulations. -
I certify that I have react 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 of covering be class"Q" or better.
hereby authorize representatives of this city to enter upon the above-mentloned property for in-
spection purposes.
(We) agree to save, indemnify and keep harmless the Cly of Cupertino against liabilities,
judgments, costs and expenses which may In any way accrue against said Cly in consequence
I A PLICANT DTE
of the granting of this permit.
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