R-4695 PERMIT R_ 4695
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
2 G(Xlsei C F, RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
2 L YES [3 If yea—I understand that a Class A
E
NAMei Q] !J r A Li S fee roof assembly is required.
'Q/ f`7 e� - NO initial— Lc.B.O.#- (13
4
ADDRESS� ' (J J bV 1150yt C L EXISTING ROOF COVERING
PHONE rr NUMBER OF EXISTING COVERINGS
CONTRACTOR'S .J (7
NAMI ea abK 70 BE REMOVED_LYS—TO BE RETAINED
ADDRESSTYPE OF ROOF COVERING
CITY&ZIP _ - -
EXISTING
PHONE ORI 7 —!J-7 7-7— BUILT-UP ROOF ❑
LICENSE
NUM ER _ ASPHALT SHINGLES ❑
LICEN ED 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 Coda,and my license Is In full force and
effect.
WOOD SHINGLES ❑
License Class C ��� Lic.Number�a/ /f �Z-
Date Contractor�l/2sf�t rAc. OTHER(SPECIFY) - ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,altar,Improve,demolish,or repair any structure,prior to its issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to Isle a signed statement that he Is licensed pursuant to the provlaIons
of the Contractors License Lmi Chaplor 9(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 subjects the applicant to
a civil penalty of not more than five hundred dollars($500).):
C]1,as owner of lhepropeN or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intanded or offered for sale(Sec.7044,Business and Profes-
sions Code:The Contractors 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 / fl .�r I
Is sold within one year of completion,the owner-Wilder will have the burden of proving that he did OTHER(SPECIFY) ` F f P
not build or Improve for purpose of sale.).
❑I,as owner of the properly,em exclusively contracting with licensed contractors to construct p
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO. '7D L 3
apply to an owner of property who builds or improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B 8 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 Workar'e Compensation, p O� .S BUidin k
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this A 1 199
permit is issued. 95 Seismic
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 ofI'f yLit-
_the Labor Code,for the performance of the work for which this permit is issued.My Worker's' L i-
Compensationlnsurance/�larrlerennd Policy number are: I', t'uYtrY(ffVU (�-lll..AVV! Total
Carrier ST0.�P flit A POIICy No. L Z',�n.S PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' poplai
COMPENSATION INSURANCE N.C.I]
(This section need not be completed if the permit Is for one hundred dollars($100)or Ion.)
I certify that In the performance of the work for which this permit Is Issued,I shall not employ
any person In any manner so as to become subject to the Workers'Compensetlon Laws of Cell- All roofs shall be inspected prior to any roofingWmabefornia. installed. If a roof is installed without firs
Date Applicant inspection,I agree to remove all new materials for inspection.
ecome
subject
.ETO APPLICANT: It,after the Workers'Compensation provisions of the Labor Code,cate of you mustufo thwiitthbcomply Applicant understands and will comply with all non point
with such provisions or this permit smi 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 state laws relating to building construction,and ll roof COV IngsIt eclass"C"or e r
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes.
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities,
• judgments,Cosa and expenses which may In any way accrue against said City In consequence IGNATURE OF AP ICANT DAT
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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
r
g
t�
rCity of,
Cuperthio
SM KEDETECTOR CERTIFICATE OF COMPLIANCE
I understand and comply with Section 1210-A of the Uniform Building Code.
Section 1210-A requires when repairs to a single family dwelling exceed $1,000, a smoke
detector will be installed, mounted on the ceiling or wall in each sleeping room and at a
point centrally located in the corridor or area giving access to room used for sleeping
purposes. If existing smoke detectors comply, no new detector shall be required.
• I understand the above requirement and certify that we now have smoke detectors
installed that do comply. ,
ADDRESS:
PERMIT NUMBER: — -4645
e.
HOMEOWNERS SIGNATURE:
DATE: I.Z -;' 0 - S
winword/smkdet
•
Pruned on Recycled Paver