R 4960 (2) PERMIT R_ 496
0
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1 DAYS PERMIT ISSUANCE OR
180 WITDAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
Z-0119
-O/19 C P vNVb l df- RESIDENTIAL--X—COMMERCIAL OTHER
OWNER'S _7HAZARDOUS FIRE AREA
NAME Keay I �+ 'I YES ❑ If yes-I understand that a Class A
roof assembly is required.
NO Initial I.C.B.O.#
ADDRESS201
Cc K ,eV EXISTING ROOF COVERING
PHONE 0 ZJ O NUMBER OF EXISTING COVERINGS:
1 CONTRACTOR'S /� /
NAME LA t-s} n re-- 120 o i YICA TO BE REMOVED� TO BE RETAINED
ADDRESS,-�I��y� `�yAn ,( /.,� 4r TYPE OF ROOF COVERING
CITY 8 zlPl'y�,",""�
W;Al
^�1✓84)d. sm Ja r_ !J i z 3 EXISTING .
PHONE (N�— BUILT-UP ROOF ❑ -•-999
LICENSE
NUMBER QJ/ F-) 39g ❑ A
ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter g(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect /x 2 /7 �e8 WOOD SHINGLES ❑ 21^/
License Oil `�`-� Lie.Number .5
Dah, 71QZfCant rec o OTHER(SPECIFY) ❑ �C
OWNER-SUILDER DECLARATIO PROPOSED
1 hereby affirm that I am exempt from the Contractor's License Lew for the following reason.
(Sec.7031,5,Business and Professions Code: Any city or county which requires a permit to
construct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provision,
• of the Contractors License Law(Chapter a(commencing with Section 7000)of Dlvlelon 3 of the ❑
Business and Professions Code)or that he to 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
e civil penalty of not more than live hundred dollars($500).):
E]1,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 sale(Sec.7044,Business and Prolee- L �� /
sionsCode:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES STLG4
Improves thereon,and who does such work himself or through his own employees,provided that ❑
such Improvements are not Intended or offeredforeels. ill however,the building man
pros Improvement /fey rd.T 1�
not
Is tbuild or
prove for purposesIon,the owner-bullderwlll have the burtlen of proving that he dltl OTHER(SPECIFY) lY ,7R ` '
not build or Improve for purpose of sale.).
❑I,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Cotle:The Contractor's License Lew does not PROVIDE I.C.B.O.REPORT NO.a rr 4 x 3
apply to an owner of property who build,or Improves thereon,and who contracts for such projects
with a contramor(s)licensed pursuant to the Contractors License Lew.
❑I em exempt untler Sec. ,B&P.C.for this reason PROVIDE MFGR.INSTALLATION SPECS.
r, owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATEI VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
s ❑f have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, �� � 713uildias provltletl for by Section 3700 of the Labor Cotle,for the performance of the work for which this permit Is haveand. ` I�1
have and will maithe pelrf Worker's f the wok for Insurance,as required su d,My
3700'of
s `
ih Labor Code,for the performance of the work for which this permit le lesuetl.My Worker's 11�
compass t n In ranee]pryer end Polynumber ars: ,� � —^� � !'7/ Total
Carrier �Yl Polley No.6-36)4/ IT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed If the permit Is for one hundred tlollem($100)or lase.) t/p t/
I certify that In the pedormance of the work for which this permit Is Issued,I shell not empToy r
any person In any manner so as to become subject to the Workers'Compensation Laws of Cell. All roofs shat 10spected prior to any roofing material being
forma. 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,after making this Certificate of Exemption,you should become Applicant understands and will
subject to the Worker,'Compensation provisions of the Labor Code,you must forthwith comply PP comply p y with all non point
with such provisions or this permit shall be 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 bul[ding construction,and JAIIrf coverings to be class"C"or better.
hereby authorize representatives of this dry to enter upon the above-mentlonetl property for In- �FXAPPLIMT
ep(We) purposes. 4(We)agree to save,Indemnify end kayI harmless the Clta ai Cupertino against Ilabllance lud menta.I Date entl expen,ea which meY In enY way accrue against aeltl CIN In consequence .,,_, �oftRegrantingofthispermit. TU
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