R 4726 (2) APPLICATION FOR CITY OF CUPERTINO NUMBER R- 4 7 21
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
• WITHIN DAYS PERMIT ISSUANCE O
1 DAYSS FROM LAST CALLED INSPECTION..
BUILDING ADDRESS
10372 Scenic Circle RESIDENTIAL 70S COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME Isbell roof assembly is required.
NO Initial I.C.B.O.# 5075
ADDRESS- same EXISTING ROOF COVERING
PHONE 255-6831
NUMBER OF EXISTING COVERINGS one
CONTRACTOR'S
NAME Heritage Roofing Inc. TO BE REMOVEDyea TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP 3987 First St. "P" Livermore CA 94550
EXISTING
.l PHONE sin-447-7508 BUILT-UP ROOF
r
CENSE 0&",
NIUMBER 595748 C39
ASPHALT SHINGLES ❑
• LICENSED CONTRACTORS DECLARATION
hereby affirm that I am licenced under provisions of Chapter B(commencing with Section WOOD SHAKES
700 0)of Division 3 of the Business and Professions Code,and my license Is In lull force and /
effect.
WOOD SHINGLES
License Claes C 39 LIc.Number
I ❑
Date 5/29/96 Contractor Steve Dunn OTHER(SPECIFY) ❑ ��
OWNER-BUILDER DECLARATION PROPOSED
hereby affirm that I am exempt from the Contractor's License Law far the following reason.
IS
7031.8,Business and Professions Code: Any city or county which requires a permit to
construct,alter,Improve,demolloh,or repair any structure,plor to Ito Issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
• of the Contractor's License Law(Chapter g(commenclna with Section 7000)of Divblon 3 of the
Buslneae antl Pro196elone Cotle)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHIN 3 Q 1996-
exemption.Any violation of Section 7031 S by any applicant for a permit subjects the applicant to
a civil penalty of not more than live hundred dollars($S00).):
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES f Uri uc u t 11N❑'
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Proles
sions Code:The Contractor'a License Law does not apply to an owner of property who builds or WOOD SHINGLES E]Improves thereon,and who does such work himself 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-builder will have the burden of Droving that he did OTHER(SPECIFY) XR Fire.Exee
not build or improve for purpose of sale.).
❑I,as owner of the property am exclusively conuactlna with licensed contractors to construct shake
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
app y to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(o)licensed pursuant to the Contractors License Law, PROVIDE MFGR.INSTALLATION SPECS.
El am exempt under Sec. ,B 8 P,C.for this reason
Owner -Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
01 have and will maintain a Certificate of Concent to sell-insure for Worker's Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit lel ed. 6/96 $12000 Seismic A. �]
ave ane will the performance
Worker's Compensation the workfor Insurance,as required by d,My
3700 0l
the Labor Code,�foyr nc petormand of the work for which this permit Is leeuetl.My Worker's
Comemotioncarrier and Policy number are: 285-96 664 Total
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O L
(This section need not be completed If the permit le or one hundred dollars($100)or lose.) o
certify that In the performance of the wor4flhW11 permit le Ise shell not emptoyany person In any manner ao ee to become eorkers'ca soon Laws o CaII All roofs shall a inspected prl r to any roofi g material being
fornla. installed. If a roof is installed without first Obtaining an
Date 5/29/96 Applica inspection,I agree to remove all new materials for inspection.
subh.
ject to thICE eOWorrkero'Compel,after ma na ton provisionls of theCarllLaborr Code,cate of Exemption,
must forthwitbecome
h comply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. Source regulations.
I certify that I have read this application and state that the above Information Is correct.)agree
to comply with all city and county ordinances and state laws ralating to building construction,and All roof Brings to be ass°C"or better.
hereby sulhorUo representatives of this city to enter upon the above-mentioned property for In.
ep(We)agrpoeae.
p(We)agree to save,Indemnity and keep harmless the City of Cupertino apCelnat Ilebllitlea, e�-
• oltlhif onto call and granting Of this Deem lees which they In any way accrue against said City in Caneequenca SZI ,NATURE 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
OFFICE COPY