R 4554 PERMIT R_ 4554 ..
APPLICATION FOR CITY OF CUPERTINO NUMBER
R-
PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
�- BUILDING 100 DAYS FROM LAST CALLED INSPECTION.
�7ADDRESS l /�I
X
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CMZ 1� �,LZ`C1 1 cflrG p_ RESIDENTIAL COMMERCIAL OTHER
OWNER'S _ HAZARDOUS FIRE REA
T'Ny^`,t u yt f g YES ❑ If yes—I understand that a Class A
NAME ' • ,] U hOZ.(+1.� roof assembly is required.
NO Initial I.C.B.O.a
ADDRESSd:41.7f:41 W 4L NO 1 r CkT I EXISTING ROOF COVERING
PHONE l — �(0 L(O NUMBER OF EXISTING COVERINGS OA-P—A'4- rDO�
CONTRACTOR'S }� f ^,y
NAME . )QM �1'(O .S T O TO BE REMOVED X TO BE RETAINED
ADDRESS �� g� SLIM 50�2, q,7 I S TYPE OF ROOF COVERING
CITY&ZIP
EXISTING
PHONE qQ _ss C1 -13? BUILT-UP ROOF ❑
LICENSE 33 $
NUMBER C-3 9 ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby eHlrm that 1 am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES
7000)of Dlvlelon 3 of the Buelnese and Professions Code,and my license Is In full force and ss.
enact. (p 1133 WOOD SHI.NJ+G'L ❑
License Clear �_� Llc.Number
OTHER � � ❑
Date � 1 e Contractor to ?� ANS
ID
Contractors
LicenseATION PROPOSED
hereby affirm that 1 am exempt from the e: Any
Llcenee Lew which
chthe following permit
t. Uf
(Sec.7031.5,Business and Professions Code: Any city or county which requires 0 permit to LUr'Cfl l fly(,/
construct,alter,Improve.demolish,or repair any structure,prior to Its Issuance, ❑also requires the BUILT-UP ROOF C,e1O"'+
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions -�e v,
of the Contractor's License Law(Chapter 0(commencin with Section 7000)of Division 3 of the A o
• 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($500).):
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑ V� �+
the work,and the structure is not Intended or offered for sale(Sac.7044,Business and Profes. Q
alone Code:The Communities License Law does not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does ouch work himself or through his own employees,provided that 1:1such Improvements are not Intended or offered for sale.It.however,the bullding or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he ditl OTHER SPECIFY
not build or Improve for purpose of sale.). (SPECIFY) ❑
❑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 Lew does not PROVIDE I.C.B.O.REPORT NO.
appy to an owner of property who bulls orlmoroves thereon,and who contracts for Such projects
with a contractor(s)licensed pursuant to the Cpontraitor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I 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: p
❑I have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, D eq1 Y) ,�O BUlldln
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this g
'permit Is issued. ` 'a1aQ(�% Seismic
bora and will maithe performance
Worker's Compensation the wokfor which this as required by d.MY
3700's
the ober Code,for the performance of the work for wrath this permit Is Issued.My Worker's v
Compene�ticn ing0re0aa"or n T.7;&
numberere: �„ A�YLcr Total
Carrier C� Policy Nob(t .-_l 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($700)or lose.)
I certify that In the performance of the work for which this permit Is Issued,I shell not empploy
Laws o
any person In any manner so as to become subject to the Workers'Compensation Lf Cell. All roofs shall b ns ected prior to an roofing 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.
NOTICE TO APPLICANT: If,ahor making this Certificate of Exemption,you should become A licant understands and will com I with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP y
with such provisions or this permit shall be deemed revoked. sours ulationst
I certify that l have read this application and state that the above Information is coned.l agree
to comply with all city and county ordinances and slate laws relating to building construction,and Allr Of coV m t0 aCle s ° r fter.
hereby authorize representatives of this city to enter upon the above-mentioned property for In. t'
ep We) purposes. 1— R 9
(We)agree s save.
Intlemnlw entl keep harmless the City ai Ct said Ci y n c n llebllen e, lY1
• of
judgments.ran costa entl expensed which may In any way accrue agelnet aeltl Clry4n consequence
of the granting of this
permit
. 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