R-4570 (2) PERMIT R_ 4 5 7 0
APPLICATION FOR CITY OF CUPERTINO NUMBER
,INSPECTION DIVISION PERMIT E%PIRATION
REROOF PERMIT c (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
1f o1 lie RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES yes—I understand that a Class A
NAME- 74/ s4 / root assembly is required.
NO ❑ Initial_i I.C.B.O.R
EXISTING ROOffCOVERING
ADDRESS
PHONE J J / NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME
—
J AM y�.I�k�:rr TO BE REMOVED_ TO BE RETAINED
ADDRESS T E OF ROOF COVERING
CITY azlP � xJO� l t „�vCy7r37 �
EXISTING
PHONE 2 9 i J- KVlr/ BUILT-UP ROOF ❑ .
CENSE
NUMBER ASPHALT SHINGLES ❑
LICE SEDC NTRACTORS 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 lull force and
effect' 2 3 WOOD SHINGLES ❑
License Class d ,r,/ Lic.Number .3 0 / �^
OTHER(SPECIFY) ❑
Date _/ Contractor
OWNER-BUILDER D ARAT N PROPOSED
hereby affirm that I am exempt from the Conirec is License Lew for the fallowing 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)of Division 3 of the nA ®q,
Business and Professions Coda)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES 'to ❑ QN ,
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to0).):
a civil penalty of not more than live hundred dollars($50WOOD SHAKES 'r(
C]1,as owner of the property,or my employees with wages as their sole compensation,will do V/- /� 1
the work,and the structure Is not intended or offered for sale(Sec.7044,Business and Proles- GGti 9j• cs4 A
sions Cotle:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES (L� U:/_N�
Improves thereon,and who does such work himself or through his own employees,provided that rO } I �� p
such improvements are not Intended or offered for sale.If,however,the building or improvement N/ (^/9 G—
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.).'
❑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 contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 em exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is Issued. /0/ 000 Seismic �
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
the Labor Code,for the performance of the work for which this permit is issued.My Worker's Total
Compensation Insurance carrier and Policy number are: �/
Carrier �A,^ • 4*r• Policy No. J/�� J PERMITAUTHORI DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' 01
COMPENSATION INSURANCE N.C.O
(This section need not be completed it the permit is for one hundred dollars
($1` o lass.)
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 roofs sit I be inspected prior to any roofing r4aterialbeing
tornie. installed. If a roof is installed without first obtaining an
crotaigillkDate 5Yi Applicant ' inspection,I agree to remove all new materials for inspection.
subject I.I.the OW
orkers'C Compensation nprolvisit ecome
of that Labor Cotle,ifate of Exemption,
mustforthwith ou should bcomply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. source regulations. -
I certify that I have read this application and stale that the above Information Is correct.)agree
to comply with all city and county ordinances and state laws relating to building onstruclion,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-
spection purposes. (a,`•�J // ?
(We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may in any way accrue against said City In consequence TrURf OF APPLICANT DATE
of the granting of this permit.
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 _ _