R 4951 (2) PERMIT R_ 4 9 51
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
FtESIDENTIAL )L COMMERCIAL OTHER
OWNER'S ' 1� aHAZARDOUS FIRE AREA
NAME \ YES ❑ If yes—I understand that a Class A
of assembly is required.
^7 Q .^. n u }� NO Initial I.C.B.O.#
ADDRESS ZI �3(' s' "`'�"�— 1 EXISTING ROOF COVERING
PHONE ;k`(7 — 5-708 NUMBER OF EXISTING COVERINGS /
CONTRALTO 'S _ 4
//7� TO BE REMOVED TO BE RETAINED
NAME—
ADDRESS
1� �-'CMC
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP 22Gi 2 L.,R, C zj�
85125 f f Pct-�m�t -� €XI$7JLI�a . 7
PHONE BUILT-UP ROOF
LICENSE ,:SG9 - 2 C-3LES U�2 ❑
NUMBER 1J 1 ASPHALT SHINGLES 09c
' LICENSED CONTRACTORS DECOU/1
f f Ur
Lta U
I hereby affirm that I em licensed under provisions of Chapter B(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
affect.
r1�y ❑
License Clesa —� Lic.Number WOOD SHINGLES�! 1 �
Date Contractor ojt• S ^^/ n OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from the Contractor's ansa Lew for the following reason.
(Sec.7031.5,Business and Proleselone Cotle: Any city ouMy'whlch requires a permit to
construct,alter,improve,demolish,or repair an tructum,' r to Its Issuancealso requires the BUILT-UP ROOF ❑
applicant for such permit to file a signs tl etatem t(hat he is ahead'Pursuani to the provisions
of the Contractor's License Law(Chapter B(co nbing wl cllop 7000)of Division 3 of the
•
Business and Professions Code)or that he Is
a pt o d the basis for the alleged ASPHALT SHINGLES ❑
exemption.Any violation of Section 7031.5 by a II e a rmll subjects the applicant to
e civil penalty of not more than five h rare tl Ealla
❑I,as owner of the property, yyembloyas It g as their sole compensation,will do WOOD SHAKES
the work,and the structure Is n In tided for ale(Sec.7044,Business and Profee-
slonsCode:TheContractor'sLienes oatppplytoanowner ofproperty who builds or WOOD SHINGLES Improves thereon,and who doep w k meeff r through his own employees,provided that E]such Improvements are not Into or o red for aaIa.If,however,the bullding or Improvement
le sold within one year of compl on, saw at. ulitlar wlllhavethebuMenol proving that he did OTHER SPECIFY
not build 1,as owner
Improve for purpose of sal ./ (SPECIFY) ��
❑I,ecowner ofthe Business-arid
azar Ively Code;The
licensed contractors to construct
the project(Sec.7044,Buelnese builds or Improv Cotle:The Contractor's License Law does not PROVIDE LC.B.O.REPORT NO. LS
apply to c nt owner of property whobuildst ore Contra thereon,and who contracts for each projects
with acontractors)nder epursuantto the Contractor's License Lew, PROVIDE MFGR.INSTALLATION SPECS.
❑I em exempt under Sec. ,B 8 P.C.for this reason
OwnerDate
WORKER'S COMPENSATION DECLARATION APPLICATION DATE V UATION 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, Building
as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which this *Oh"L,
g
permit is lveuetl.❑ have entl wool the peirf Worker's C thewok for Insurance,ee rmit Is Is by Section 3700 0l l / $BISm
ic
,the Labor Code,for the performance of the work for which this permit le leeuetl,My Worker's
Compensation Insurance carrier and Policy ere: Total
Carrier Policy No.z�— PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.M
(This section need not be completed If the permit Is for one hundred dollars($100)or less.) (\�J
I certify that In the performance of the work for which this permit I Issued,I shall not employ
any person In any manner so as to beaom the W mpeneetion Laws of calf All roof^shdll be inspected prior to any rooting material being
fornia. installed. If a roof is installed without first obtaining an
Date IAApplica inspection,I agree to remove all new materials for inspection.
NOTICE APPL CANT: IL eller m g lhla Certificate Exemption,you should become Applicant understands and will cora
subject to the Workers'Comp permit
pn l).be die m d the Labor Code,you must forthwith comply PP ply with all non point
with such provisions or rola permit shelObe deemed revoketl. SOUfCe regulations.
I certify that I have read this application and state that the above information is correct.)agree
to comply with all city and county ordinances and state laws relating to building construction,entlCover. be CIS "C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In. ^
spectlon purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, 1
judgments,costa and expenses which may In any way accrue against said City In consequence
• �#
of the granting of this permit. SIGNATURE OF APPLICANT 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