R-4929 PERM
NUMBER
RR- 4929
CITY OF CUPERTINO
APPLICATION FOR
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1110 DAYS OF PERMIT ISSUANCE OR
• 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS ./
RESIDENTIAL vCOMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES C] If yes—I understand that a Class A
NAME roof roof assembly is required.
p NO ❑ Initial I.C.B.O.#
ADDRESS i O 37'7 V 1 S �Y101L $`V Ol EXISTING ROOF COVERING
PHONE 515 Cp
NUMBER OF EXISTING COVERINGS
i CONTRACTOR'S �y
NAME Mnc_J JM }�jrau e-. - IAS TO BE REMOVED TO BE RETAINED y�
ADDRESS ^.� /��� 1 TYPE OF ROOF COVERING
CITY&ZIP A%n �Jar S. ` w . t"Inr[8w.1W( �. q�1 7 NG
'u` — EXISTI
PHONE O Ip S -'IAA BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES ❑ r p
LICENSED CONTRACTORS DECLARATION
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. WOOD SHINGLES A 6 -91996
License Clens G•3!J Lic.Number as!i
Det.2-9. 9(o Contractor J1M Kraetbb OTHER(SPECIFY) / r ,l>rim,
0 �-'•�^••r Ott)
OWNER-BUILDER DECLARATION PROPOSED �/
I hereby e8irm that I am exempt from the Contractor's License Law for the following reason.
cons.construct,
It Business and Professions Coda: Any Illy pr county which requires e permit to
construct alter,improve,to file signed statement
anystructure,prior to its Issuance,t also requires the BUILT-UP ROOF
applicant for such permit to Ills a signed statement mat he it licensedactio pursuant to the provisions
of the Contractor's scion Law(Chapter 8(commencing with Section 7000 Cf Division 3 oilhe
Bushes and violation of Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES ❑
axe
civil pen.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to `^
e civil penalty a not more than floe my
dollars th wage: WOOD SHAKES S `
❑I,es ownerofthe property,or to employeeswith wages as their sole Business
and will s-
the work,and the structure Is not Intended or offered for bale(Sac.7044,Business end 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.It 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.).
❑I,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 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 coniractor(s)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 APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
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, _ _�/1 Building 2,
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this /VY"�)I.J
permit is have
I Seismic
❑I have and will maintain Worker's Compensation the Wo kfor Insurance,as required by Section Workers
s f x
the Labor Code,for the performance of the work fon which this permit is Issued.My Workers Total xL
Compensation Insurance ca�rtl rend Policy number are:
Carrier SQ J V h�• Policy No.?RT 'Q�-3• PERVT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.J
r (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,1 shall not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of C.11- All roofs shall be inspected prior to any roofing material being
fornix installed. It a roof is installed without first.obtaining an
Dat. Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It after making this Certificate of Exemption,you should became Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the labor Code,you must forthwith Comply PP P Y P
with such provisions or this permit shallibe deemed revoked. source regulat
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 slate laws relating to building construction,and All roof cc gs to S"C"or better.
hereby authorize representatives of this City to enter upon the above.mentloned property for in.
spection purposes.
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may in any way accrue against said City in consequence I PPL PATE
CI 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