R-4682 PERMIT R_ 4682
.
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS 1/` I �+ (^ /�
I O 33 V ' 'dS< 6A_, RESIDENTIAL COMMERCIAL OTHER
OWNE ' /j� /off S+ Q HAZARDOUS FIRE AREA
NAME C2:1 1 1 \O / 1 U /) YES ❑ If yes—embly is
stand requirad Class
'E.� roof assembly undo is required.
NO InNal I.C.B.O.M
EXISTING ROOF COVERING
ADDRESS
PHONE - 0L.(1 V NUMBER OF EXISTING COVERINGS f '
COr Sw�R' O
flS /�Q TO BE REMOVED—j—TO BE RETAINED
NAM 1 1
ADDRESSI--(�(,
yy TYPE OF ROOF COVERING
aTv 8]IP ` &41EXISTING
PHONE F' C L1. 93 - (0223 BUILT-UP ROOF
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed undar provisions of Chapter B(commencing with Section WOOD SHAKES E]]000)of Division 3 of the Business and Professions Code,and my license Is in full force and
effect' WOOD SHINGLES P A I D ❑
License Class(� Lic.Number
OTHER(SPECIFY) ❑
Data Contractor 91996 1996
WNER-BUILDER DECLARATION 4f- rRal /JJU
1 hereby affirm that I em exempt from the Contractors License Law for the following reason. PROPOSED
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to CITY OF CUPEH
construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the BUILT-UP ROOF Ni'
applicant for such permit to file a signed statement that he is licensed pursue nt to the provisions
. of the Contractors License Law(Chapter S(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 subject.the applicant to
e civil penalty of not more than five hundred dollars($500).):
01,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES
the work,and the structure Is net Intended or offered for sale(Sec.7044,Business and Profes.
sions Code:The Contmctor's License Lew does not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,end 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.7044,Business and Professions Code:The Contractor's License Lew does not PROVIDE LC.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 Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. .B It P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: /�
r71 have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, I Building
as provided for by Section 3700 of the Labor Code,for the performance 01 the work for which this
permit is issued. 11\ 1 Seismic
❑ have and will the performance
Worker's Compensation f Insurance,as required by Section 3700's
the Labor Coda,for the performance o/thew k for which this permit Is Issued.My Worker's Total
Compo o Insure a sorter Polity nu or ere:
Cam Poly N5.' (_•"71VIVw' PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
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 shell not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of call- All roofs shall be inspected prior to any OOf g material being
torrid. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTCecome
subject I.Ethe TO APPLICANT:
Compensation prrovisions of the tiLabor cate r Code,you must fo thwf Exemption u she lltlhbcomply Applicant understands and will comply with all non point
with such provisions or this permit shell be deemed revoked. source regulations. -
I certify that 1 have read this application and stele 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 covenrigs to be class"C"or better.
hereby authorize representatives of this city to anter upon the above-mentioned property kr In-� 1 19
hereby
purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against ilabilitles,
• judgments,costs and expenses which may in any way accrue against said City in consequence IGNATURE OF APPLICANT �DAA'f�
el 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