R-4553 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO
NUMBER R— 4553
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS r �[
RESIDENTIAL "` COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES E] If yes-I understand that a Class A
NAME S( o "_P1'nA S Nhq roof assembly is required. �`
NO V.4- Initial Kr I.C.B.O.It
ADDRESs �o�a� "•�n �r �SQI"C EXISTING ROOF COVERING
PHONE 2 SI " O NUMBER OF EXISTING COVERINGS -� W 0
CONTRACTOR'S .1- a I1
NAME Q (S J TO BE REMOVED 7� TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
CITV&ZlP Zbb� Col. (`we s-s��� (� A
p q •� EXISTING
PHONE ^U'SS BUILT-UP ROOF �J �jQQ sot-P+
1`�� O C- �`�� ASPHALT SHINGLESZlLJ^a
' LICENSED CONTRACTORS DECLARATION
1 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 Cade,and my license is in full force and
effect' _ WOOD SHINGLES
License Class �" � Lic.Number �'`��� ❑
Date 1071_7-61 5 Contractor Da OTHER(SPECIFY) ❑n
OWNER-BUILDER DECLARATION -�
I hereby affirm That I am exempt from the Contractors License Law for the following reason. PROPOSED o T
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to C/ -1 1�LI! ��7
construct,alter,Improve,demolish,or repair any structure,prior to Its issuance,also requires the BUILT-UP ROOF •4 95
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)of Division 3 of the
Business and Professions Code)or that he is exempt therefrom and the basis far the alleged ASPHALT SHINGLES UC Business rt I II U
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to V
a civil penalty of not more than five hundred dollars($500),): WOOD SHAKES ❑
I,as owner of the property,or my employees with wages as their sole compensation,will do
the work,and the structure is not intended or offered for sale(Sec.7044,Business and Profes.
sions Cade:The Contractor's 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 dict OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
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 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 contractors)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT F E
WORKER'S COMPENSATION DECLARATION + p
hereby affirm under penalty of perjury one of the following declaration:
\o'_4O� l� 1d, —.
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, ` ` BUlldln
as provided for by Section 3700 of the Labor Code,for the podormance of the work for which this
permit is Issued.
41 have and will maintain Workers Compensation Insurance,as required by Section 3700 of Seismic
the Labor Code.for the performance of the work for which this permit is issued.My Workers Total
Compensation Insurance carrier and Policy number are:
Carrier -SW<<�' policy Na_? S "Sko PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.Q
(This section need not be completed If the permit is for one hundred dollars(5100)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 Cali- All roof^shall be inspected 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 became Applicant understands and will 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 shalllbe deemed revoked. Source regulations.
I certify that I have react this application and state that the above information is correct.)agree
to comply with all city and county ordinances and state laws relating to building construction.and All roof Brings tob cass"C"or better.
hereby authorize representatives of this city to anter upon the above-mentioned property for in-
spection purposes
(WI1/—1-1]
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, l
. ludiimant%costa and expenses which may In any way accrue against said City in consequence SIGNATURE OF APPLICA DATE
of the granting of this permit.
PRE-INSPECTION: PLYWOOD: IN-PROGRE '
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