R 4964 (2) PERMIT R_ 49 6 4
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
((//�
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
7 L / p YES If yes—I understand that a Class A
NAME_S Q, I root assembly is required,
�� �Ia 1 � ` NO El Initial I.C.B.O.#
ADDRESSt701 `a�� �^CJL.-_ EXISTING ROOFOF COVE COVERING
PHONE S 9
nA — � 1 NUMBER OF EXISTING COVERINGS I
CONTRACTOR'S L Q �
�A41-I M-0V✓� nhA/' C � TO BE REMOVED TO BE RETAINED
NAME In 1" �l�-�� l.i'r'1w
ADDRESS sw Md'3 nl\E��s LY S7' lq�J TYPE OF ROOF COVERING
CITY 8 ZIP ba��'- `7 ll.:Xf..��
EXISTING
PHONE 4'I —y�rq 3� BUILT-UP ROOF ❑
LICENSE
NUMBER 5245G� ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter a(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Cotle,and my license Is in full force and
effect. ^�
LJ WOOD SHINGLES
License Clea Lie.Number
O],L/J,"�' ❑
Date Contractor
OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Professions Code: An city or county which requires a permit to
construct,alter,improve,demolish,or repair any of urs,prior to its Issuance,also requires the BUILT-UP ROOF E)applicant for such permit to file a signed statement a Pe licensed pursuant to the provisions
' of the Contractor's License Lew(Chapter g(comma I with Section 70001 at Division 3 0l the
Business and Professions Code)or that he Is axe t erelrom and the basis for the alleged ASPHALT SHINGLES ❑
exemption.Any violation of Section 7031.5 by any ap for a permit subjects the applicant to
e civil penalty of not more than five hundred Bakers' )
1,as owner of the property,or my ergpl a e their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intgg d`o ar I ac.7044.Business and Proles-
elonsCotle:TheConirecmr's wlae'Lewtl s apPlyloenowner ofproperty who builds or WOOD SHINGLES Improves thereon,and wh such w h or through his awn employees,provided that ❑ T,/�n, ITY�
such Improvements he fnt n for sale.If,however,the building or Improvement t( f OPJ- l v'!
Is sold with in one ye Ir oI mpl If th pwnor-builder will have the burden of proving that he did OTHER(SPECIFY) ) �(,�-,n
not build or Improve for pu o �a.. a
01,ea owIt roltha pr er em exclusively contractin with licensed contractors to construct r�O l O
the project(Sec.7044,Busin and Professions Code: he Contractor's License Lew does not PROVIDE I.C.B.O.REPORT NO. _1 7
apply to an owner of property wh builds or Improves thereon.and who contracts for such projects
with a contractor(a)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
01 em 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 fallowing declaration;
❑I have and will maintain a Certificate of Consent to shall-Insure for Worker's Compensation, Building
-as provided for by Section 3700 of the Labor Code,for the performance of the work for which this /��/�1 g
permit is Issued. �s Seismic �w
❑ have and wool the performance
Worker'rmancee f the work
for Insurance,she requiredsu section 3700 0l ( ` �/v
the Lobar Code,for me performance of the work for which this permit Is issued,My Worker's � A
Compensatl��471neur�en_ce ceryl 16d, li1c�'\number are: Total 04
Carrier • r ' ` `� L�'yv PolicyNo.a�,—G010-7
PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.p `
(This section need not be completed If the permit Is for one hundred dollars($ 0)
m lees.)
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'Compepeetlon Laws of Cali. All roofs shall be inspected pricirlb any r0 Ing material being
fornix' roof is installed without first obtaining an
Date Applicant"' J� inspection,I agree to remove all new materials for inspection.
NOTICE ot APP CANT: If,aftermaking this fthelLab of ode,you mustuforthwshould
lmbecome
ompl Applicant understands and will comply with all non point
subject to the Works a'Compensation king the of the Labor Code, comply
with such provisions or this permit shall be deemed revoked source regulations.
1 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.
g(We)agree to save,Indemnity and keep harmless the City of Cupertino alalnet liabilities,
' oltRa onto coal and grenting of this pamlexpenses which they In any way accrue against said Clry n Consequence SIGNATURE O PPLICANT AT
PRE-INSPECTION: PLYWOOD: N-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