R 4548 (2) PERMIT R_ 4548
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 'np '/�.
oa-9 S S�ICY 1 I �� RESIDENTIAL COMMERCIAL OTHER
OWNERS 1,. ' I Rill-nn
�'/�/�, �}'�/'� HAZARDOUS FIRE AREA
NAME 1�l+$ . � Fes] J ll�-(► n VES ❑. I�f assembly s rrequirred. Class A
n *ib
NO ❑ Initial I.C.B.O.#ADDRESS 105 r �`f 1' t )tq� (�►yr L`•, EXISTING ROOF COVERING
PHONE — ey' I 1 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME44-a-lks-a-i
TO BE REMOVED TO BE RETAINED
ADDRESS I TYPE OF ROOF COVERING
CITY 8 ZIP. EXISTING
! PHONE BUILT-UP ROOF ❑
LICENSE c
NUMBER J ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 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
effect.
1�•I WOOD SHINGLES
License Class Lic.Numb4AM'cityor
. OTHER(SPECIFY)Date ContractoOWNER-BUILDEPROPOSED
I hereby affirm that I am exempt from the Conow for the following reason.(Sec.7031.5,Buelneae entl Professions Cotle: which requires
a parmlt to
construct,alter,Improve,demolish,or repair any sir ni,prior to Its Issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement t is licensed pursuant to the provlslons
. of the Contractor'sProfessions
License Law(Chapter h(com ahcI ,Section 7000)of for the 3 of the
ex
Business tio end Prolotion of Code)or that he Is e t aro om and the base for the applicant
to ASPHALT SHINGLES
exemption.Any ltyof oft more
lhanSection 703dredit to n4for e permit subjects the eppli<enUo
e civil penalty of not mora then live hundred f.):
❑1,as ow no of the property,orm ii a with wages as their sole compensation,will do WOOD SHAKES ❑
the work,entl the structure la not arT r flared for sale(Sec.7044,Business and Prefer.
sionsCoda:ThaConlrector'eLice div tlam not apply to an owner of property who builds or WOOD SHINGLES
improves thereon,entl who tloas a rkhlmself or through his own employees,provided that ❑
such improvements are not Intended or offered for sale.If,however,the building or Improvement
is sold within one year of completion,the owner-bulkier will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or improve for purpose of sake.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's Loanse 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 Contractor's License Lew, PROVIDE MFGR.INSTALLATION SPECS.
E]I em exempt under Sec. ,B&P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penally of perjury one of the following declaration: ka d 0
❑I have and will maintain a Certificate of Consent to sell-Insure for Workers Compensation, [ N Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit Is issued. Seismic
I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of 1r'r'g
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's JJ�A7
- Compensation lnsurange carrlor end Policy qumber ere: I (,litf M Total
Carrier ,rF�i f��V—Ila/._VT_=�— Policy No. PERMIT AUTHORIZATION`I"yL DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
• COMPENSATION INSURANCE N.C.p
(This section need not be completed if the permit is for one hundred dollars($100)or leas.)
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'Compensenan Laws of Cell- All roofs shall be inspected prior to any roofing material being
fornka. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
ecome
subjects to the Workers'CompeCE TO APPLICANT: nsation provafter isionthils ofethefiLabor Code,Crticate of yolu mustufothwllshouthbcomply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. SOUrCEI regulation
I certify that l 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 budding construction,and All roof coy ass"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes. /'
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, /� V
. of the granting of this permit.ae which may in any way accrue against said City in consequence E 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