R-4835 (2) PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 4835
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
-z2194� McCieIIQ-`^ Izoe�el
RESIDENTIAL 'X` COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
L YES ❑ It yes-I understand that a Class A
YV7
NAME l I D"Q root assembly is required.
NO ❑ Initial I.C.B.O.#
ADDRESS
221 l McC self an I�OcIC� EXISTING ROOF COVERING
_
PHONE (40 --&P2 �2 NUMBER OF EXISTING COVERINGS g�j
CONTRACTOR'S
NAME �a.nnJ LCk TO BE REMOVED v TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
CITYBZIP )t7U �J .Saicyl wAA/ C�D2rtihu
pp EXISTING
PHONE L U-�$ �Z S3-i38 U' BUILT-UP ROOF ❑LICENSE
pp
NUMBER .� 66�99� ASPHALT SHINGLES ❑ O�n "
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7111 of Division 3 of the Business and Professions Code,and my license is in full force and
effect' WOOD SHINGLES ❑
License Class Lic.Number –1
Date–?/ Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLAR N PROPOSED
I hereby affirm that I am exempt from the Contractors License Lew for the I ing reason. I�
(Sec.7031.5.Business and Professions Code: Any city or county which requires a permit to P , ^
construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the BUILT-UP ROOF ElRJ
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions /��
O
of the Contractor's License Law(Chapter 9(commencing with Section]000)of Division 3 of the
• Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES V
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than live hundred dollars($500).): WOOD SHAKES ilk Or[]
1,as owner of the property,or my employees with wages is their sole compensation,will do e1Yp . b
the work,and the structure is not intended or offered for sale Sec.7044,Business and Probe-
Sierra
Coda:The Contractors 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
not bull ori year purposetofsal eownarbuildar will have the burden of proving that he did OTHER (SPECIFY)
not ljimW orimprove for purpose completion,
solo.).
❑1,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. Zo 9
apply to an owner of property who builds or improves thereon,and who contracts for such projects
with a contractogs)licensed pursuant to the Contractor's License Law. PROVIDE MFGR. INSTALLATION SPECS.
❑1 am 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: li
❑ / ` ' .�
1 have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, 2)A �� Building jilt –/�_
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this 7
permit I issued. Seismic Z
Cjf have and will maintain Workers 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 6 "4'�`o edla4 'E Policy No. awG �Z` 3g–� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.p
(This section need not be completed if the permit is for one hundred dollars($100)er less.) ?,—:3/
"� V
I certify that in the performance of the work for which this permit is issued,I shall not employ l �T
any person In any manner so as to became subject to the Workers'Compensation Laws of Cali- All roofs shall be inspected prior to any roofing material being
forma. installed. If a roof is installed without first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,alter making this Certificate of Exemption,you should become A licant understands and will com I with all non oint
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP P y P
with such Previsions or this permit shalQbe 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 roof cover'ngs to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes.
(We)agree to save,indemnity wand keep harmless the City of Cupertino against liabilities.
judgments,costs and expenses which may In any way accrue against said City in consequence SIGNATURE APPLICAN 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY