R 4847 (2) PERMIT R_ 4847
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
Amok 180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS/^� ,," I y-� t//
,9f � 1 1 e�-i I�Q `—+ , • RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
P I I f s YES ElIf yes—I understand that a Class A
NAME 1 , 1 'r� � loof assembly is required.
^ NO - Initial I.C.B.O.p
ADDRESS I�P 1 Cl Wil_-C-Y'L� EXISTING ROOF COVERING
PHONE 41S Or4NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
RO�jGJ_J_. 1 c� TO BE REMOVED TO BE RETAINED
' NAME
ADDRESS �` L�rCD�(�1 �e TYPE OF ROOF COVERING
CITY&ZIP
EXISTING
PHONE x0(4 -4400 BUILT-UP ROOF ❑
LICENSE
NUMBER C_-yQ �� ASPHALT SHINGLES ❑
'T
LICENSED CONTRACTORS DECLARATION
1 hereby elfirm 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 full force and
effect WOOD SHINGLES ❑
License Class Lie.Number4n 1
oreJ)1n`! h Contractor OTHER(SPECIFY) - ' ❑
OWNER-BUILDER DECLARATION PROPOSED MAY 6
1 hereby affirm that I am exempt from the Contractors License Law for the following reason. 10(]C
(Sec.7031.5,Business and Professions Code' y city or county which requires a permit to 1j96
construct,alter,improve,demolish,or repairany r turag,,prior to Its Issuance,also requires the BUILT-UPrRQOFjr ❑
applicant for such permit to file a algnetl slatemen t fi6is licensed pursuant to the previsions V
of the Contractors License Law(Chapter 9(corarr99 Ing with Section 7000)of Division 3 of the Ur LI 1l 11 yl/
Business and Professions Code)or that h ie.eka a rom and the basis for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 e r a permit subjects the applicant to
a civil penalty of not more than five hu tlfbd 5001.):
❑l,as owner of the property,or am awith wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is n Io IS do 10 Credit for sale(Sec.7044,Business and Protea.
alone Code:The Contractor n does not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and wh o ork himself or through his own employees,provided that ❑
such improvements are no.{ d d or offered for sale.If,however,the building or Improvement
Is sold within one year of compo n,the owner-builder will have the burden of proving that he ditlOTHER(SPECIFY) Elnot 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 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(a)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
r]I em exempt under Sac. ,S 8 P.C.for this reason
Owner Date
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 37 a of
cateLab of Consent to ePerforma for Worof the
Compensation ton, �b�9b r1 1^,—.., BUIIChn
peprit Is for by Section 3700 olthe Labor Code,for the Performance of the workforwhich this '^_`'ll fooll lJJ) g
permit Issued.
have and will maintain Worker's Compensation Insurance,as required by Section 3700 of Seismic
.,the Labor Code,for the performance of the work for which this permit Is issued.My Workers
Compensation Insurance carrier and Policy number are: Total
Carrier 1Q LJY� Policy No. 0 1? I'll,I& f PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.GD
(This section need not be completed If the permit Is or one hundred dollars($100)or less.)
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 Cell. All roofs shall be inspected prior to any roofing mat ria being
fornla. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: of Exem
subject o the Workers'Compeneatlon provisionafter makinis of theflLabor Code,cate yolu mustufo thwlithbecome Comply Applicant understands and will comply with all non point
with such provisions or this permit shalfibe deemed revoked. source regulations.
I certify that I have read this application and state that the above Information le correct.I agree
to comply with all city and county ordinances and state laws relating to building construction.and All roof coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentloned property for in
ap purposes. n(t) t r r V-4-���1 . _ �`
(We) �
(We)agree to save,Indemnity and keep harmless the City of Cupertino against Iieblllllee, „lA,� IIX�-pl I1111Vn�V'is�ia
judgments,costs and expenses which may in any way accrue against Said City Inconsequence SI ATURE OF APPLICANT
of the granting o/this permit. 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY