R-4828 (2) APPLICATION FOR CITY OF CUPERTINO
NUMBER PERMIT
R- 4828
INSPECTION DIVISION AZ PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
80 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
11 737 PAIR 7%1-ee
erT/N6 ✓` RESIDENTIAL /_ ` COMMERCIAL OTHER
OWNER'S /Q �! r P'/ HAZARDOUS FIRE AREA
NAME :57 - G-9 •—y� YES ❑ If yes—I undemland that a Class A
roof assembly Is required.
/0 737( l �` , r� NO Initial I.C.B.O.A
ADDRESS f��,D�*/ill
/�� �,lets S�'�/� EXISTING ROOF COVERING
PHONE �� 7s"6 — 7YI6 NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S n —��1
TO BE REMOVED TO BE RETAINED
NAME �( / /`KT/ w —!Y✓�
ADDRESS �O'� S 770g, 571 Gy TYPE OF ROOF COVERING
7S//Z
y
CITY aZIP/'/ ! � EXISTING
PHONE/`� � �9 Z j6 y7/ � BUILT-UP ROOF
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am 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
effect
7 L�17l WOOD SHINGLES
License Class Lic.Number s *�
OTHER(SPECIFY)
Dale 9.6 Contractor ��np pK
OWNER-the oER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the requires
a reed
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
condiruct,forer,
Improve,demoto file signed statement
anystructure,prior to its issuance,to thprovirequires the BUILT-UP ROOF Of Y ❑
applicant for ouch permit to flaw a Signed Statement that he Is licensed pursuant to the provisions
of the ss and
License Lew(Chapter B(commencing with Section]000)of for
3 of the Vr'Cry
Business end Professions Coda)or thet he Is exempt therefrom and the basis for the scant to ASPHALT SHINGLES ❑ f hY(�
.' exemption.Any ltyofolt more
lhanSection ehundrbyany s($50ntfor a permit subjects the ePPllontto
a civil penalty of not mora then five y employees
dollars with
wage WOOD SHAKES 1
❑I,es owner of the property,or teemployeeswith wages as their sole compensation,will do ❑
the work,and he structure Is not Intended or offered or eels(Soo.7040,Business entl builds
o-
sions improv improves
n.an whodoessuchworks orthroughhsowneapply to an owner 1ployerty es.pro provided
at WOOD SHINGLES ❑
Improves oven,end who does deco work edforhimself or through his own employees,provldetl that
such Improvements are not completion,
or offered for leer.ill however,the enof pr or improvement
Is not
or
year of for purpose
sthe ownerbuilderwillhave the burden of proving that heorf OTHER(SPECIFY) ❑
not bulM or Improve or purpose of sale.).
❑I,as owner of the property,em exclusive 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
with a contractor(s)licensed pursuant to the Contractors License Lew. PROVIDE MFGR.INSTALLATION SPECS.
Owner
am exempt under Sec. ,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: O
Q 1 have and will maintain a Certificate of Consent to sell-insure or Worker's Compensation, BUlldln
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is Issued. $eISmIC
Fj I have and wlI maintain Worker's Compensation Insurance,as required by Section 3700 of
the Labor Code,for the performance of the work for which this permit la Issued.My Workers I 4L Total ,
Compensation Insurance carrier nd Policy number are:
l
Carrier m. Policy No. / PERMIT AUTHORIZAT1111ION DATE
CeRTIFICAYE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑ � Pr I
(This section need not be completed If the permit is for one hundred dollen($100)Or lase.)
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'Co dation Law.of call- All roofs shall be inspected prior to any roofing material being
fornix. _ installed. If a roof is installed without first obtaining an
Date 3:/ Applicant inspection,I agree to remove all new materials for inspection.
subjectto the wok Workers'Compef,after nsaton provisiones of the La or Cotle,rtni pole mualuorthwiithShould comrly Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. y py sourceregulations.
I certify that I have read this application and state that the above Inormatlon Is correctI agree
to comply with all city and County ordinances and state laws relating to building construction,and All roof coverings/to be S"C"or better. /
herebypurr authorize representatives of this city to anter upon the above-mentioned properly for In. �Jw!/
herebyn purposes.
(Al agree to Save,Indemnity and keep harmless the City of Cupertino against liabilities,
judgments,
granting of this perrmit ea which may In any way accrue against saitl Clry in consequence �G TURE APPLICANT DATE
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