R 4947 (2) PERMIT R_ 4947'
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 �.// Q
/04/)<7_6L7GL /V�( D� RESIDENTIAL COMMERCIAL � OTHER
OWNER'S - _ HAZARDOUS FIRE AREA
//,� yn I n ,w� �/ I YES ❑ If yes—I understand that a Class A
NAME `fAl PLT(�0 OCVA) l lx`W off /1 550CxQP roof assembly is required.
NO t Initial— I.C.B.O.#
ADDRESS- Z053-0 73-w
) CI PNTtI- AA)e EXISTING ROOF COVERING
PHONE 1/�J / L�CO V SOS . NUMBER OF EXISTING COVERINGS
CONTRACTOR'S r
NAME SlPAN
TO BE REMOVED____(�)_TO BE RETAINED D��
ADDRESS Z 3 A) Z 'STTYPE OF ROOF COVERING
CITY 8 ZIP S OAK�-�0 •
/ EXISTING
PHONE` �o�� y3 S — O �/ZO BUILT-UP ROOF
LICENSE Q 3q_ 9q O ASPHALT SHINGLES
NUMBER ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter g(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Proleeelona Code,and my licence le In lull force and
e#eat, ^ �/ Q q'l WOOD SHINGLES ❑
License Cleea ` f� Lic.Number / U
Data Z ' — Contractor Ak37N-A) 4e r'&U 40of_ OTHER(SPECIFY) ❑
OWNER.BUILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from the Contractor's License Low for the following reason.
(Sac.7037,5,Business and Professions Coda; Any city or county which requires a permit to
construct,alter,Improve,demolish,or repair any strum prior to Its Issuance,also requires the BUILT-UP ROOF El
for such permit to file a signed at to ant that licensed pursuant to the provisions
of the Contractor's License Law(Chapter g(commencl f4ection 7000)of Division 3 of the
. Business and Professions Code)or that ha le a{{ertlpt I from and the basis for the alleged ASPHALT SHINGLES ❑
exemption.Any violation of Section 7031,6 by ppn`applica9ermll subjects the applicant to
e civil panefly of not more than live hundred rJoIII (
❑Lae owner of the property,or m employeea a as their sole compensation,will do WOOD SHAKES ❑
the work,antl the structure Is not hde r r sale(Sec.7044,Business and Proles
alone Code.The Conlractar'a LI neo Le t apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,antl who tlpb eu hl elf or through his own employees,provided that ❑
such improvements are not Intan or for sale.If,however,the building or Improvement
Issold within one year alcompldl oqq ao er-bulkler will have the burden of proving that he did OTHER(SPECIFY) ^"v(1/e //
not build or Improve for purpose of all —G r—
❑I,eeownerofthe property,am, Illusively contracting with licensed contractors to construct
the project(Sec.7044,Business end 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 contractor(s)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR. INSTALLATION SPECS.
❑1 em exempt under Sec. ,B a P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under paneiry of perjury one of the following declaration: "
❑I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, Building
as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which this AI q�
permit Is Issued, �V �/ 9QS ` Seismic
®1 neve antl will maintain Worker's f the work
for Insurance,as required by Section 370001 b
the Lebon Cotle,for me performance of the work for which this permit to leauetl.My Worker'ei�}'
Compensatioonn Insurance cper'rim end P Ilcy number are: y� L(Jj-Cr. n,f� Total
Carrier ST TG �//(�� Policy No.1373005 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C. (_
(This section need not be completed It the permit Is for one hundred dollars($100)or lees.) C�
I certify that In the performance of the work for which this permit Is Issued,I shell not amploy
any person In any manner so as to become subject to the Workere'Compensation Laws of Call- All roofs shall be inspected prior to any roofing material being
torula' 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: II,after making this Certificate of Exemption,you should become
subject to the Workers'Compensation pprovisions of the Labor Code,you must forthwith comply Applicant understands and will comply with all non point
with such provisions or ihla permit enal¢'be doomed revoked. Source regulations.
I certify that 1 have read this application and state Mat the above Information la correct.)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.
ep ction(We)purposes. 6 ,7 ^�
(We)agree to save,expenses
and keep hay way the City ai Cupertino a sinal liabilities,
of the I ar costa and expellees which may In any way accrue against said City 4n consequence
of the granting of this permu. SIGNATURE OFA LICANT DATE
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
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