R 4753 (2) APPLICATION FOR CITY OF CUPERTINO
NUMBI ERR- 47:5:3 ]
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN DAYS PERMIT ISSUANCE OR
WI DAYSS FROM LAST CALLED INSPECTION.
49 BUILDING ADDRESS
2/,5'J 6 RESIDENTIAL COMMERCIAL OTHER
OWNER'S (SJJ p v l`/ / [ - HAZARDOUS FIRE AREA
NAME /4�1 x/T �`J�� YES ❑ It yes-I understand that a Class A
root assembly Is required.
I� / NO Initial I.C.B.O.g
ADDRESS^/slz Rc(,,NAR f EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTS S TO BE REMOVED ` TO BE RETAINED
NAME yto%f CC rlr�hLSTRUGTia�(
ADDRESS P.LJ , /JQ 47)3,
CITY& �CA TYPE OF ROOF COVERING
ADDRESS O
//� G /� /• EXISTING
PHONE 1 908 `(e?Cry—0160 BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect. /' lk5— w WOOD SHINGLES J]
Llcen ee CI ae Lie.Number/-�
IM? Contractor
DW ELL a GDAGS174(XJYOy OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Lew for the following 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,prior to Its lsau e,also requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is licensed pur the provisions
• of the Contractors License Law(Chapter g(commencing with Section 70 l Sion 3 of the
Business and Professions Code)or that he Is exempt therefrom and be to the alleged ASPHALT SHINGLES ❑exemption.Any Any violation of Section 7031.5 by any applicant for a pe subjects pplicent to
a civil penalty of not more than five hundred dollars($500).):
C]I,as owner of the property,or my employees with wager heir nation,will do WOOD SHAKES
the work,and the structure Is not Intended or off4ny
t (S .7 u nese and Prolea-
aloneCode:The Contractor's License Lew dowo Iproparty who oulltle orWOOD SHINGLE$Improves thereon,and who does such work l' n employees,provitletl Net ❑such Improvements are not Intended or often Poever,the building or Improvement
la sold within ane year of completion,the owner-be"the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,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 Lew. PROVIDE MFGR. INSTALLATION SPECS,
❑I am exempt under Sec. ,B a P.C.for this reason
Owner
WORKER'S COMPENSATION DECLARATION APPLICATION DATE1 VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: PAID
$ p
-x El have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, W
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this Building
permit is Issued. oo Seism 1C
❑ have and will maintain Worker's Compensation Insurance,as required by Section 3700 0l d
the Labor Code,for the performance of the work for which this permit is Issued.My Worker's
n' 1�96 C sensation Insurance carrier and Policy number are: C' &,,A Total
Carrler Policy No. ,/ "PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' V
COMPENSATION INSURANCE N.
(This section need not be completed If the permit Is for one hundred dollars($100)or see.)
I certify that In the performance of the work for which this permit Is Issued,1 snail not em toy
any person In any manner so as to become subject to the Workers'Compensation Laws of all. All roofs shall be inspected prior to any roofing material 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: If,after making this Certificate of Exemption,you should become Applicant understands and will
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP comply p y with all non point
with such provisions or this permit ehalQbe 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 buildingc.nsl uctlon,entl All r f coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
ep(We)agrposes. (��d
(We)agree to save,expenses
and keep harmless cc City of Cupertino against Ilebllltle9,
•
of
gra,granting
of and permit. which may In any way accrue against said City..,wneapuence
ohne granting of ima permit. SIGNATU OF APPLICANTSIGNATU OF APPLICANT AT�
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