R-4894 (2) PERMIT R_ 4894
.
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
• WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
.�` c..l,w a.ow
zZ9 y 36 q41 � [. G RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ II yes—I understand that a Class A
NAME t a/G `�SA 0., 5 �✓ \ I root assembly is required.
ma
` c NO Initial I.C.B.O.11
ADDRESS I x, S5 —t riV_ ,11A la. MC'-CIO, EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S �
NAME �Ia.v I't 1n,d TO BE REMOVED TO BE RETAINED
ADDRESS �/+ .� TYPE OF ROOF COVERING
CITv a zlP l a� .]o_ 5�. .74x1 JD 5e- EXISTING
PHONE L,4Vg� BUILT-UP ROOF ❑
LICENSE # ❑NUMBER
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES 2J
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect _ r ' WOOD SHINGLES ❑ Zit
License CIe s r • 1 1 r �j
Date Con OTHER(SPECIFY) C ❑
OWNER-BUILDER DE 1M N PROPOSED
I hereby affirm that I am exempt from the Cantrec r9 U nse Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any ci county which requires a permit to ^x�
construct,alter,Improve,demolish,or repair any struct poor to Its Issuance,also requires ins BUILT-UP ROOF MAY 4 1.M?t16
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions LLL777
of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the C(TV U!- L Uri
Busfnass and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES tY❑VU Q
axe mption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to L
a civil penalty of not more than five hundred dollars($500).): WOOD SHAKES
C]1,as owner of the property,or my employees with wages as their sole compensation,will do ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes.
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES E]improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for sale.If,however,the Cu l Iding or Improvement /'e
Is sold within one year of completion,the owner.builder will have the burden of proving that he did OTHER(SPECIFY) ®C ^k)O_,Z�
not build or Improve for purpose of sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contrectar'B License Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractar(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 em exempt under Sac. ,B$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 self-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 ,`y-tvL
per isissued. 1�.' �' ) )(.� 8�� Seismic 4.4a
have and will maintain Worker's Compensation Insurance,as required by Section 370001 r"/ l7
the La bar Code,for the performance of the work for which this permit Is Issued.My Worker's
Compare rencarrler gp6�p11cy qumber are: w Total
F C\� �T.s�16Zf�' ` 1 p[� �6tioc
Carrier g. E Kh. Pi No. PERMIT AUTHORIZ-51OZI DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 100)o
(This section need not be completed if the permit is for one hundred dollars($100)or lase.) `
I certify that in the performance of the work for sued I shall not employ
any person In any men er so as to becom ea the Worker a aeon Laws of an All roofs shall be inspected prior to any roofing m ens
forma. installed. It a roof is installed without first obtaining an
oats / inspection,I agree to remove all new materials for inspection.
NOT14 TO AP LICANT: If,after making this of ption,you should become Applicant understands and will comply with all non point
subject to the We ars'Compensation provlslone f the bar Code,you must forthwith comply PP P Y
with such provisions or this permit shall t tleem ked. s0 U a I .
I certify that I have read this application and state that the above Information is correct.)agree All roof coverin CI S O better.
to comply with all city and county ordinances and state laws relating to butting construction,antl y j
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spectlon purposes. /� q
(We)agree to save,Indemnlly and keep harmless the City of Cupertino against liabilities, l
judgments,costs and expenses which may in any way accrue against said Clry Inconsequence SI T A ANTATE
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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY