R 4660 (2) PERMITR_
APPLICATION FOR CITY OF CUPERTINO NUMBER 4666
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN DAYS PERMIT ISSUANCE OR
WI DANSS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
IQ'\ a j�1/�
• LDI v H� , 'V ` I o + RE�SIDENTIALZ—COMMERCIAL OTHER
OWNS S A (] HAZARDOUS FIRE AREA
NAM LZ 1 �" u Q 'n r`-c YES ❑ royof assemby slreq requind that red. Class A
NO )g InitiI I.C.B.O.#
ADDRESS " 1 e EXISTING ROOF COVERING
PHONENUMBER OF EXISTING COVERINGS I
1 CONT T�OR'S A•�• �
NAM I nq TO BE REMOVED. TO BE RETAINED
ADDRESS HC SQ.,,.�v,kl. 1� .(��—q TYPE OF ROOF COVERING
CIN&21P '�1}• `/ 1 1r' XISTING
PHONE 1 `����� BUILT-UP ROOF
LICENSE ❑
NUMBER ASPHALT SHINGLES
LCENSED CONTRACTORS DECLARATION
I hereby a# I
Irm that I am lceneatl under provisions of Chapter S(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Cotlp,an my license Is In lull force and
effect.
WOOD SHINGLES ❑
License CI se C.Numoer
Date conthisOTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION t PROPOSED
I hereby allirm that I em exempt from the Contractor's License Lew for the 11 In reaeon,
(Sac.7037,5,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 A 8 �]
applicant for such permit to file a signed statement that he Is Ilceneatl pursuant to the provisions
of the Contractor's License Low(Chapter g(commencing with Section 7000)of Dlvlelon 3 of the
Business and Professions Code)or that he Is exempt t arefrom 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 'JA5�] qD U
a civil penalty of not more than five hundred dollars($500).): [��
[2 1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ,.aLy�,
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes. l��n (Jr �Ur(:r{I INIJ
alone Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLE.? I' 1
Improves thereon,and who does such work himself or through his own employees,provided that ❑
such Improvements are not Intended or offered for sale.it,however,the building or Improvement
1...to within one year of completion,the owner-builder will have the burden of proving that he did OTHER
not build or Improve for purpose of sale.). (SPECIFY) ❑
❑1,as owner of the property.am exclusively contracting with licensed contractors to construct
he project(Sec.7044,Business and Professions Code:The Contractors 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 contrec or(s)licensed pursuant to the Connector's License Law.
❑I em exempt under fisc. .B 5 P.C.for this reason
PROVIDE MFGR.INSTALLATION SPECS.
Owner WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby a#Irm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Cenlllcate of Consent to self-insure for Workers Compeneafion,
permit Is Is for by Seunlon 3700 of the Labor Code,for theperformance of the work for which this l ^���� Building
permit le ed for b (`.'/I
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of Seismic
the Labor Code,for the performance of Via work for which this permit Is Issued.My Worker's Total
campgpse{lo Ineur//nce ler entl Poll number are: -5� ' '125 �/'
Carrie.`\> r Policy No. 7 PERMITAUTHORIZATION DA E
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.[]
(This section need not be completed If 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 shell not em joy
any person In any manner so as to become subject to the Workers'Compensation Laws of dell- All roofs shall be inspected prior any roe Ing material being
lornia. installed. If a roof is installe without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE a APPLICANT: If,after making provis title Certificate of Code,
mus ushould become
forthwith comp) Applicant understands and will comply with all non point
subject to T APPLICANT:
NT: If,a ter provisions of the Leber Code, y
with such provisions or this permit shall be deemed rooked. 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 building construction,and All roof coverings to be c s"C"or etter.
hereby authorize representatives of this city to enter upon he above-mentioned property for In-
selection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino epainet liabilities,
ludp.ante,costa entl expenses which may In any way accrue against ealtl City Inconsequence
onheereotmgorthle permit. SIGNATURE OF APPLICANT DATE
4��
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 , I