R 4945 (2) PERMIT R_ 4 9 4 5
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 Pogo(
T fl Ile fia r 1l RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
VES If yes—I understand theta Class A
NAME �1t-ti7 W f roof assembly is required. /- P
NO ❑ . Initial t:/• I.C.B.O.a
ADDRESS 21 71 C T fP h a Vf RQC,d EXISTING ROOF COVERING
PHONE 1? 6 -"7/U( NUMBER OF EXISTING COVERINGS
�- CONTRACCT�O�R�I aX /� /` TO BE REMOVED SLtA�2 TO BE RETAINED t t1.B.1
' NAME `�Y/1W� �IA U�+1. �Q�f" l QI�G_
ADDRESS / 1 ? Ql In C 0� Jn ne, gs�/a TYPE OF ROOF COVERING
CITY B ZIP
(f�ob) yy/ -033 EXISTING
PHONE / BUILT-UP ROOF ❑
LICENSE S� S-7' ASPHALTSHINGLES
NUMBER ❑
LICENSED CONTRACTORS DECLARATION r� -
I hereby affirm that I am licensed under provisions of Chapter g(commencing with Section WOOD SHAKES II�YVt
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and '
enact. WOOD SHINGLES
License Claes Uc.Number Sae"r f"I
A�s//II��ppx�y X,t/(n,(�µ, q OTHER(SPECIFY)
Date OWNER-BUILDER
LD/✓LfLry.I
OWNER-theCnOECLAMTION PROPOSED 't ^
hereby affirm i net am exempt from the Contractors or county
Lew for the following reason. //� >
(Sec.7031.5,Business and Professions Code; Any city or county which requires a permit to Vl/
construct,altar,Improve,demolish,or repair any structure,prior to Its issuance,also requires the BUILT-UP ROOF .24 ❑
applicant for such permit to lila a signed statement that he Is licensed pursuant to the provisions 7 t
• of the Contractor's License Lew(Choptar g(commencing with Section 00)�OfDlviflon 3 of the8u91nese entl Proleaelone Cotle)or that ho la exempt therefrom end t r the ellegetl ASPHALT SHINGLES(/_exemption.Any violation of Section 7031.5 by any applicant for aperme s a applicant to
e civil penalty of not more than live hundred dollars(11500).)t�-❑1,as owner of the property,or my employees wghwages as el o §atlon,will do WOOD SHAKES �U ❑
the work,and the structure Is not Intended oro for sale SB n se and Proles.
alone Code: The Contractor's License Lew, ikt ap c property who builds or WOOD SHINGLES
Improves thereon,and who does such work' a ssr ro own employees,provided that ❑
such Improvements are not Intended or oflerr�� eAO�,.Irnowever,the building or Improvement
Is sold within one year of completion,the ownhrr*30orwill have the burden of proving that he did OTHER(SPECIFY) I 1
not bund of Improve for purpose of Bale.).
❑I,as owner of the property,em exclusively 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(e)licensed pursuant to the Contractors License Law, PROVIDE MFGR.INSTALLATION SPECS.
C]I am exempt under Sec. ,B 8 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
1 hereby affirm under penalty of perjury one of the following declaration:
s ❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Building
as provided for by Section 3700 of the tabor Code,for the performance of the work for which this 'w n I^ �IS g
permit Is Issued. rfvl a'N I'1� seismic
❑I have and will the pert Worker's Compensation Insurance,as required by Section 3700 of
the Labor code,kr the performance of the work for which luta permit Is lasuetl.My Workers
CompBnsBt1 n Ins//urwance carrier end Policy number are: Q (� Total
Carrier ��'C- � � Policy No. 429 �-� "9 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need not be completed If the permit Is for one hundred dollars($100)or less.)
1 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 roof^shall be inspected prior to any roofing mate Tal being
fornia. installed. If a roof is installed without first obtaining an
Date S� Applicant inspection,I agree to remove all new materials for inspection.
subjectI.theE TtWorkers'ic mpenseionprovis�nisofthelcate of LaborrCode,youmustforou lthwlithocomply Applicant understands and will comply with all non point
with such provisions or this permit shairbe deemed revoked. source regulations.
1 certify that l have reed 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.
spectlon purposes.
(We)
(We)ogres is save,Indemnity and keep harmless the Clry ai Cupertino against liabilities, 1
0 he gots,coats antl expenses which may In any way atelia against 991tl City In consequence
oitnegrantingolthlsperm0. SI ATUREO PPLICANT DATE
PRE-INSPECTION: PLYWOOD: ZPROGRESS..
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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