R 4710 (2) PERMIT R_ 471
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
BUILDING ADDRESS
180 DAYS FROM LAST CALLED INSPECTION.` ✓/-
1 RESIDENTIAL COMMERCIAL OTHER
OWNER'SHAZARDOUS FIRE AREA
� / YES ❑ If yeas I assembly
is req ire . Class A
NAME JSP J'L a r h a Na lir .-) O H W s.s roof assembly is and(hat
NO ❑ Initial I.C.B.O.K
ADDRESS 7112/ .l'i r ear_ e-'.r.�r� EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRA OR. 11 /
NAME rte •+.� sw,f/rae firsw TO BE REMOVED ✓ TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP-,fSC /�utc.i N. �n. KV, /JAM,IL EXISTING
PHONE !f 06r- 7JG- d/ 9 BUILT-UP ROOF ❑
NUMBER — ASPHALT SHINGLE ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Cotle,and my lice as Is I force and
effect.
WOOD SHINGLES
License Class Lie.Nu
Date er /
T� Tg s Cant actor OTHER(SPECIFY)
'
OWNER BUILDER DECLARATION PROPOSED
hereby affirm Bu met em exempt from the Contractors License Lew for the following reason.
const 7031.5,Business and Professions Code: Any city or county Issuance,
requires a permit to
construct,alter,Improve,demolish,signed air stateny mentrthat a Iprior to itsslicense l pursuant els oreprevisthe BUILT-UP ROOF ❑
eppllcent tr each permit to file aChaptstatement that g ithlcen do 7000)of
the previsions the /
of the Contractor's License Law(Chapter B(commencing with Section 7000)of Division ale theBusiness LJ
exemptio and violation of Coda)or thet he Is exempt therefrom and the bells for the alleged ASPHALT SHINGLES
exemption.Any violator of than
five 7031.5 by any sapplIcant0t for a permit subjects the applicant to
e civil penalty of not more then nue hundred dollars($500).):
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for Bele(Sec.7044,Business and Profes.
sions Code:The Contractors License Lew does not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who doe.such work himself or through his own employees,provided that ❑
such Improvements are not Intended or offered for sale.If,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contractlnp with licensed contractors to construct
Th
the project(Sec.7044,Business and Professions Code: e Contractor's License Law does not PROVIDE LC.B.O.REPORT NO.
apply to wnerof property who builds or Improves thereon,and who contracts for such projects
wuneg, exempt neer Se pursuant to the Comre<rore License Lew. PROVIDE MFGR.INSTALLATION SPECS.
CIN
exempt under Sec. ,B$P.C.for this reason
owner-,, Dela
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: 7
0 have and will maintain Certificate of Consent to sell-insure for Workers Compensation, O� Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this J 7
permit ill ed. CJ N
ova
and will maintain Worker's Compensation Insurance,as required by Section 3700 of Seismic O
the ebar Code,for the performance of the work for which this permit is Issued.My Worker's /` 4
Compensation Insurance terrier and Polls umber are: Total tl
Carder STi4Tf% PoIIcyNo. d]l yrD09y7 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' _
COMPENSATION INSURANCE N.C.0
(This section need not be completed If the permit Is for one hundred dollars($100)or lees.) � �/'"7a�'sd/C
I certify that In the performance of the work for which this permit Is Issued, shall net em loy `J
any person In any manner so as to become subject to the Workers'Compensation Laws of all. All roofs shall be inspected prior to any roofing material being
fornix. 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,alter making this Certificate of Exemption,you should become
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shell be deemed revoked. source regulations. n P I
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 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. T1 8199
(We)agree to sous,Indemnify and keep harmless the Clry of Cupertino against Ilabllillse, .JDs Qti7J/�VCc-, r
jud manta,coats antl expenses which may In any way accrue against veld City In consequence
oftge gm Ing
ofhis permit. SIGNATURE OF APPLICAp}T. DATE
PRE-INSPECTION: PLYWOOD: IN-PROGRESS
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