R-4703 (2) PERMIT R_ 4703
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (406)777-0226 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
910 CDfl� w°fl) RESIDENTIAL COMMERCIAL OTHER
OWNER'S - I HAZARDOUS FIRE AREA
pm" (J aa�s YES ❑ If yes-I understand that a Class A
NAME 1l /Fool assembly Is required.
NO E_- Initial I.C.B.O.N
ADDRESS— EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS l
CONTRACTOR'S`` ,,r ,{� 1 _ (•
NAMEyafmGS N ' SL t Jr. ��twl TO BE REMOVED ( TO BE RETAINED O
ADDRESSTYPE OF ROOF COVERING
CITU 8 ZIP
2`l9 Sas S•�, gSIIo.
yp /' EXISTING
PHONE 2 /-/_ v If 2-o BUILT-UP ROOF ❑
LICENSE
NUMBER Gz,0 nfl`i ASPHALT SHINGLES
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
effect. G37gq�/ WOOD SHINGLES ❑
License Class Ul Nurn
Dates cpnuac OTHER(SPECIFY) ❑
OWNER-BUIL PROPOSED
I hereby affirm that I am exempt Irom the Contractor's has L 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 provisions
of the Contractor's License Law(Chapter 9(commencing with Section 7000)at 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 live 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 sale(Sec.7044,Business and Profes.
,Ions 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.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.).
EJ I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or improves thereon,and who contracts for such projects
with a conlractogs)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECIARATION
I hereby affirm under penalty of perjury one of the following declaration: t
❑I have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, S ) Building *1 s
as provided for by Section 3700 of the Labor Code,for the performance of the work far which this Ov
permit Is Issued. Seismic
eve and will maintain Worker's Compensation Insurance,as required by Section 3700 of
the or
Code,for the performance of the work for which this permit is issued.My Workers
y I' �,on� , A�r+/e'
Compensation Insurance carrier end Policy number are: xvJ �.+` V Total
kms. _f_y Z 2o7o'IT. ��`'
Cl Policy No. pERMIT,AUTHORZATION DATE
CERTIFICATE FROM WORKERS'
COMPENSATION INSURANCE
N.C.❑
(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 person in any manner so as to become subject to the Workers'Compensation Laws of Cell- All roofs Shall be inspected prior to any roofing material being
fornix' installed. If a roofisinstalled 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 WIII comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP P Y P
with such provisions or this permit shalQbe deemed revoked. source re ulations.
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 0of ICE
gs to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes. O
(We)agree to save,Indemnity and keep harmless the City of Cupertino against Iia N 1�
judgments,costs and expenses which may in any way accrue against said City in co equence
of the granting of this permit. APPLICANT DAT
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