R-4832 (2) PERMIT R_ 4832
APPLICATION FOR CITY OF CUPERTINO NUMBER
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
Z 7-1 — Z Z D nin w RESIDENTIAL COMMERCIAL OTHER
OWNER'S to HAZARDOUS FIRE AREA
—� YES 9 If as—I understand that a CI�A---
NAME` e rzs � S d A. roof assembly is required/ J.9 7
q NO ❑ In �!/ I.C.B.O.N
ADDRESS 16 3'i f �..� ��0.^'Ltd4,S �°o- /51z I EXISTING ROOF COVERING
PHONE { ' -iz- " I Z -7 b NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME TO BE REMOVED TO BE RETAINED
10.�-f �c(' I_oU ..i�. .
ADDREs 1 p� Q11 Iq TYPE OF ROOF COVERING
EXISTING
PHONE BUILT-UP ROOF ❑
LICENSE u
NUMBER L 5^Z p j o ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Sec WOOD SHAKES X7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect. 00,
G- 39 415 20 i b �� WOOD SHINGLES E]License Class Lia Number
Date q-?,- Y , contractor IrOTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors License Law for the following 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,poor 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
Business and Professions Code)or that he Is exempt therefrom 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
a civil penalty of not more than five hundred dollars($500).):
SHAKES
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes.
sions Code:The Contractor's License Law does not apply to an owner of property who bullds 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-bullder will have the burden of proving that he did OTHER(SPECIFY) ® Cgry.xJo
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
w9h a contractor(s)licensed pursuant to the Contractor's License Law. . PROVIDE MFGR.INSTALLATION SPECS.
1 am exempt under Sec. ,B&P.C.for this reason
Owns rDate
WORKER'S COMPENSATION DECLARATION -APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, BUllding
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this n��
permit is issued. APR 5 egg $—Y,15 oc> $BISmIC
p I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
Ina Labor Code,for the performance of t�work for which this permit Is Issued.My Worker's ;;ITY Ur Total
Com ensetlon Inaurence carrier ntl Poli< number are: LtI�L(,f IIY1
Carrier a�� w� Policy No. 1 �6 PERMIT AUT RIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.I]
(This section need not be completed If the permit is for one hundred dollars($100)or leas.)
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 Wnrkers'Compensation La a of can- All roofs stlall be inspected prior to any roofing material being
fomia. p installed. If a roof is installed without first obtaining an
—
Date —O — `a� Appllinspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Cer)ifl of Exemption,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of 1�abor Code,you must forthwith comply
with such provisions or this permit shall be deemed revoked. 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 -to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In- q
spection purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may In any way accrue against said City In consequence S G R 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 _ __