R-4625 (2) PERMIT R_ 5
APPLICATION FOR CITY OF CUPERTINO NUMBER 4 6 2
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
• WITHIN 160 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
/0 (0800 CQ x 0.0 l/P9 RO. RESIDENTIAL__X_COMMERCIAL OTHER
OWNER'S /'�/ / HAZARDOUS FIRE AREA
NAME—We/ K! yl/ VE 'I It yeas assembly
is eq that.l Class A
root assembly is required. Z
�y n /� NO InNal ��- I.C.B.O.A ZA f3
ADDRESS f 6/6� 6cRGiovA „D. C(4#ff v,V,. EXISTING ROOF COVERING
PHONE 4/"/b- 1737
NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S /�
NAME
K�� Kf /) F'I/1/�s Co. TO BE REMOVED TO BE RETAINED
/��
ADDRESS
TYPE OF ROOF COVERING
CITY s ZIP y Lr.J7r�1�I�N 5% fl�(o�C.t �Y
EXISTING
PHONE SGo ��& 77 BUILT-UP ROOF ❑
LICENSE
NUMBER yZyL7� ASPHALT SHINGLES El
LICENSED 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 Code,and my license is In full force and
affect' WOOD SHINGLES ElLicense Class G w,39 Lie.Number �2y=Y3
Date to-11-93, Contractor ArNlGMr 4&bF4jl 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,alter,Improve,demolish,or repair any structure,prior to its issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to Elle a signori statement that he Is licensed pursuant to the provisions
of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professlons 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).): WOOD SHAKES El
theas owner of the property,or my employees with wages as their sole compensation,wlf do
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profes-
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLESElimproves thereon,and who does 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 I ,
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.). 4r `
I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Lew does not PROVIDE I.C.B.O.REPORT NO. Zl
apply to an owner of property who builds or improves thereon,and who contracts for such projects
with a contraclogs)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 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 Worker's Compensation, A Buildin
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is Issued. OCTI
❑I have and will maintain Workers Compensation Insurance,as required by Section 3700 of Seismic
.the Labor Carie,for the performance of the work for which this permit Is Issued,My Worker's C I 199 ^ if Total
Compensation insurance carrier and Policy number are: J f�
Carrier R!_p4MrL 1+�t1[r����s• Policy No. 1 YY�3 v• r cPERMITfAUTHORIZATION DATE
CERTIFICATE OF E%E TION FROM WORKERS'
COMPENSATION INSURANCE N.C.0 -
(This section need not be completed It the permit is for one hundred dollars($100)or less.)
. I certify that in the performance of the work for which this permit Is issued,I shall not employ
any pereon In any manner so as to become subject to the Workers'Componsatlon Laws of Call. All roofs shall be inspected prior to any roofing material being
fom a.• installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
subject too theOWorers'C Compensation prroivsionis of theficate of Exemption,Laborr Code,you mustuforthwlithbecome
comply Applicant understands and will comply with all non point
with such provisions or this permit shi lfbe 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 stale laws relating to building construction,and All roof cove to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
ape We, purposes. 0_/,-4r
(We)agree to save,Indemnify and keep armless the City of Cupertino against liabilities,
abitee, /
ofjudgments,the gran costa and expenses which may in any way accrue against said City In consequence SIGNATURE OF APPLICANT DATE
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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
_ _ OFFICE COPY _ __