R 4840 (2) APPLICATION FOR CITY OF CUPERTINO NUMBER R- 4 8 4 0
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-32'28 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
WI180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
04 /7 /Avoo014 /S�
t RESIDENTIAL COMMERCIAL OTHER
OWNER'S // HAZARDOUS FIRE AREA
YES [:] If yes—I understand that a Class A
NAME �C.�l�C /� roof assembly is required
r Q '/ NO Initial I.C.B.O.B
ADDRESS ( �v �7 X V4L lS//,11' 4a EXISTING ROOF COVERING
PHONE
7 61_� NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S
EJ,,,. TO BE REMOVED TO BE RETAINED
NAME �v
/�lJ_ AAj
ADDRESS2 �+ // p TYPE OF ROOF COVERING
CITY 6ZIP— �" —�Z �li�l..0/W L '
/ �Q EXISTING
,.
PHONE `7 � — O6 Cf BUILT-UP ROOF rtt B ❑
LICENSE �7 2
NUMBER �' / L ASPHALT SHINAIR 2 31996°
LIC NSED CONTRACTORS DECLARATION
hereby affirm that I am Ilcensed under provisions of Chapter S(commencing with Section WOOD SHAKES
700 0)of Division 3 of the Business and Professions Coo,and my license Is In full force and CI I Y Lh- IxUYCtS I
effect. ��jj
�� � ojt ( G�63,1/D(J—l3 � WOOD SHINGLES
License Close Lie.Number
Date r' 9G Contractor OTHER(SPECIFY) E]OWNER.BUILDER DEC ARATIO 7PROPOSED
I hereby affirm that I am exempt from the Contractors Lice ew for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or&Only which requires a permit to
construct,alter,Improve,demollah,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed statemen that he Is licensed pursuant to the provisions
of the Contractor's License Lew(Chapter g(cor
omm ting with Secllon 7000)of Division 3 of the Q n
—• Business and Professions Code)or that he le axe t-therefrom and the basis for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 yanya p is for a permit subjects the applicant to h
a civil penalty of not more than live hundre to 1: WOOD SHAKES (/
❑I,as owner of the property,or my§moo wages as their sole compensation,will do ❑ Ya /
the work,and the structure at Inten or ed for sale(Sec.7044,Business and Proles.
atone Code:The Contra re Clcen es not apply to an owner of property who builds or WOOD SHINGLES ❑
Improves thereon,and E5 c rk In or through his own employees,provided that
auto Improvements are
or olleretl for sale.If,however,the bulltling or improvement
la Sold within one year of 'let n,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpo of Asia.).
❑I,as owner of the property,am exclusively contracting with licensed conlractora to construct
the project(Sec.7044,Business and Profasslons 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($)licensed pursuant to the Conlractora License Law. PROVIDE MFGR.INSTALLATION SPECS.
C]I am exempt under Seo. ,B 8 P.C.for this reason
Owner oats
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the fallowing declaration:
[:11 have and will maintain a Certificate of Consent to selbinaure for Worker's Compensation, Building
A
provid d for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is Issued.
❑ .a 7 ,Cf'/ ?000r 00 Seismic
have and will maintain Worker's Compensation Insurance,ee required by Section 3700 0l `/ rP
the Labor Code,for the p dormancy of the work to hich this permit Is Issued,My Worker's
Compensa Insu c trier antl P number re: Total
carder P011cyNo. 4&t3039100- PERMIT AUTHORIZATION DATE
CERTIFICATE E E PTION FROM WORKERS'
COMPENSATION INSU N.C.p
(This section need not be completed If the perml for one h Cr d dollars($100)or lase.)
I certify that In the performance of the work for hlch t per a is$u . anal)not employ
any person In any manner co sale become eubl tom rk Cc nsallon Laws of call- All roots shall be inspected prior to any rooting material being
fornia. installed. If a roof is installed without first obtaining an
Dale Appllcenl inspection,I agree to remove all new materials for inspection.
subjectioEne WTO mkeraCCompefnaellon provislaof oiehtef Certificate
r as w�m�=aloinwi�hb omolY Applicant u rands and will comply with all non point
with such provisions or this permit shall be tleemed revo Source f lations.
certify that lhave r$etl this eppllcatlon and stere theft Dove Information le correcLlagree
to comply with all clryand county ordinances antl state la relating to building construction,one AIIr co eringst eclass"C"or better.
hereby authorize representatives of this city to enter upon the above-menllonetl property for In-
sp(We) purposes.
(W$)agrees save,expenses
and keep harmless w as the City ai Cupertino said Ci against liabilities (/
of t mems,floats And expenses which may In any way accrue against sold City in consequence
ar tRe granting of tete permit. Al E F A PLICANT 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY