R 4807 (2) PET
APPLICATION FOR CITY OF CUPERTINO NUMBER R— 4 8 0 7
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
• -
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
WI180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS /; /' 1/L //1/-� ,, o t�(
(O I Pat"' �/ RESIDENTIAL "` COMMERCIAL OTHER
OWNER'S �'t-L,Ip-en J l HAZARDOUS FIRE AREA
/pf,, p YES ❑ If yes-1 understand that a Class A
NAME_C ao � Pill&4-y% , ��j C roof assembly is required.
7 11t 5' 41S' L.05 q L+6% 1171 10 NO Initial I.C.B.O.If
ADDRESSL Inpccl S. y 45032.(. -25`f� EXISTING ROOF COVERING
PHONE
4 - 7 8 NUMBER OF EXISTING COVERINGS I
CONTRACT
NAME
ti TO BE REMOVED TO BE RETAINED
ADDRESS l�( K41�✓1 ///T.Vi C)'(G q . Y RING
CITY&ZIP 8 7 EXISTING APR p Q q
` PHONE ql (p / •2� BUILT-UP ROOFyT, R �" 19%'
LICENSE 2Co I O� 4r,` ()I- LU
NUMBER l ASPHALT SHINGLES �cNlllEl
LICENSED CONTRACTORS DECLARATION _
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES FKYI�\
7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and ,
effect. ❑
License Close if- S9 Llc.Number - t 011
p l ' WOOD SHINGLES
Date I--k contractor S Cd OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED '
I hereby affirm that I em exempt from the Contractor's License Law for the fallowing reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,alter.Improve,demolish,or repair any structure, or to its issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he i ensed pursuant to the provisions
of the Contractors License Lew(Chapter 9(commencing wit ction 7000)of Division 3 of the -
Business and Professions Code)or that he Is ex pt therair no the basis for the alleged ASPHALT SHINGLES ❑
exemption.Any violation of Section 7037.5 by any Ilcdnt for It subjects the applicant to
a civil penalty of not more than five hundred dollen ).
01.as owner of the property,or my em to a awih a eir sole compensation,will do WOOD SHAKES ❑
the work,and
the structure le not Ince o to a an owner
of Business and Profen
'lone Code:The Contractor's License go t an owner of property who builds or WOOD SHINGLES
Improves thereon,antl who does euro or I� If t rough his own employees.provided that ❑
such Improvements ere not Intend or led breals.If.however,the building or Improvement 1
Is sold within one year.of complation,tNao F6ullder will have the burden of proving that he die OTHER(SPECIFY) � ^' 1 ✓Q
not b or Improve for purpose mala.). !�
❑1.I,ae o owner of the property,em exclusively contrecting with II<ensed 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 Cambodians)licensed pursuant to the Contractor's License Lew, PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Building
as provided for by Section 3700 0l the Labor Code,for the performance of the work for which this g
n permit Is Issued. _I Q I Q��(� Seismic
❑ have and will maithe performance
Worker's Compensation the work
Insurance,as required is u d.My
3700 0l / ` ` SD l
toe Leber Code,for the partormand of the work r a which this permit Is issued.My Worker'
Compen on Ins rants carrier entl PoJtt/y number are: _�i Total
y Carried,-, e 9'^�h�` Policy N52L'-9 'l(E 0 I PERMIT AUTHORIZATION DATE-
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed if the permit Is for one hundred dollars($700)or lose.) O
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 Cali- All roDfF s all be inspected prior to Shy roofing material being
forms installed. If a roof is installed without first obtaining an
Date�0 Applicant inspection,I agree to remove all new materials for inspection.
subject t.the WT CE TO ork fsCCompef.after nsatlon ppmvislonis oftheicate of Labor Code,you mustforthwith loecome
omply Applicant understands and will comply with all non point
with such provisions or this permit shol.be doomed 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 coverings to be class°C°Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes. I
(We)agree to save,indemnify and keep harmless the City of Cupertino agalnst liabilities, �A1
judgments,costs and expenses which may In any way accrue against said City In consequence
of the grating of this permit. SGNA URE 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
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