R 4602 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBERR_ 460
2
INSPECTION DIVISION PERMIT EXPIRATION
' REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
BUILDING ADDRESS
180 DAYS FROM UST CALLED INSPECTION./039/ S4.0kes / L"(/ RESIDENTIAL ✓/
COMMERCIAL OTHER
OWNER'Sp AZAR R A A
NAME fit r NIq C Ib 4u eR YES ❑ If yea I understand that a Class A
root assembly is required.
NO ❑ Initial I.C.B.O.M
ADDRESS /USYDf{eS AyPe EXISTING ROOF COVERING/
PHONE
NUMBER OF EXISTING COVERINGS `
L
NAME C Orpt f7
CONTRACTOR'S TO BE REMOVED Sinn G TO BE RETAINEDCon1�S�O'?G �dt.).h/✓1 C. ja:_
ADDRESS SM 9y w41�R 1,O 1.✓1 r Silly. 9Sl r 8 TYPE OF ROOF COVERING
CITY&ZIP �I
PHONEJ��xcy EXISTING
— O / 269_?613 BUILT-UP ROOFLICENSE
' ❑
NUMBER G- /c IZCj ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
hereby affirm that em Business
licensed under Professions
o Chapter B(commencing with Section WOOD SHAKES
7000)of Division 3 0l the Bualneee entl Proleselone Cotle,entl my license Is In lull torso entl
effect, / WOOD SHINGLES El
License Clas$ 4-33 LIc.Number—(may Z0/v/
Date Cr�ZZ'Q S Contractor Cokrs�2S�orrG �a3�rY OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION V PROPOSED
I hereby,affirm that I em exempt from the Contractor's License Law for the following reason. /
(Sec.]031.5,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 Law(Chapter 0(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 JJ
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of not more than five hundred dollars($500).):
❑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 Prcfes-
alone Code:The Contractor's License Lew does not apply to an owner of property who bulds or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,provided that A
❑ p Q
such Improvements are not Intended or offered for safe.It,however,the building or Improvement P
Is sold within one year of completion,the owner-bulider 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 ff��
the project(See.7044,Business and Professions Code:The Conlmctors License Lew does not PROVIDE I.C.B.O.REPORT NO.SFY
apply to an owner of property who builds or Improves thereon,and who contracts for such prolecte
with a contractor(a)licensed pursuant to the Contractors License Lew. PROVIDE MFGR.INSTALLATI^^N SPECSf Cry(IIVV
[DI am exempt under Sec. ,B 8 P.C.Mr this reason y..t
OwnerDate
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: V✓ ,' p V U
❑I have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, 5-L900 �� Building 1
as provided for by Section 3700 of the Labor Code,for the performance of the Work for which this (f p
permit Is lveuetl. Seismic •/V
❑ have and will the performance
Worker's Compensation the wokfor Insurance,as required by Section Worker's of
the Labor Code,for the.performano of the work for which this permit Is Issued.My Worker'° 12 3 p
Compensation Insurance carrier and Polley number are: Total 'G
Carrier Policy No. PERMITAUTHORIZATIO DATE
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 les°.) - / 9
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 any ro ting material being
forma. installed. If a roof is installed without first obtaining an
Date 9'ZZ-4'S Applicant inspection,I agree to remove all new materials for inspection.
NOTICE ecome
subject to the OWorkers'C Compensati,afteron parovlalonis of the Laborr Code icate of Exemption,
mustforthwith ushould bcomply Applicant understands and will Comply with all non point
with such provISIena or this permit°hall 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 stets laws relating to bulltling 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. -�.I /D �{ •+� n�t�
• (We)agree to save,Indemnify and keep harmless the City of Cupertino against Ilabilltiee
oncosts and aes which may In any way accrue against said C
f the grating of this permit. lty Inconsequence SIGNATURE 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