R 4931 (2) PERMIT R_ 4931
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
c 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS 75/77 S' hTo Plot'Cl
C i4IO e N 41 h O 4 C,4 q5- 01V Elv�
COMMERCIAL OTHER
OWNER'S AZARDOUS FIRE AREA
erstand that a Class A
NAME (�� /'L/ 0 r�L�n / ly Is required.firtilal I.C.B.O.#ADDRESs 7777 "Sy [Jn/1` ��p � ��e ISTING ROOF COVERING
PHONE v T7 NUMBER OF EXISTING COVERINGS
CONTRACTOR'sQ0 �` T')n TO BE REMOVED�TO BE RETAINED-,
' NAME I2CJOT �19.�V��...L �IGn
ADDRESS TYPE OF ROOF COVERING
CITY& IP S610O k to
�/a g EXISTING
PHONE a-9 . - 1 BUILT-UP ROOF
LICENSE C 3R
NUMBER 5 0 68 ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES El
711of Division 3 of the Business and Professions Code,and my license Is in full force and
affect.
License Class C- 39 S� �� WOOD SHINGLES ElLic.Number
Data 4(2 Contractors n of 61(A a✓121 OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby allirm that I am exempt from the Contractor's License Law for the following reason.
(Be..7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,alter,Improve.demolish,or repair any structure, to Its Issuance,also requires the BUILT-UP ROOF
applicant for such permit to lila a signed statement that he I d pursuant to the provisions Q
of the Contractor's License Law(Chapter g(commencing with' 7000)of Division 3 of the
Business and Professions Code)or that he is exempt hil lr dhe basis for the alleged ASPHALT SHINGLES - nG
exemption.Any violation of Section 7031.5 by any applicant 1 It subjects the applicant to 7V
a civ11 penairy of not more than five hundred dolls h( r
aeownsr of the property,army employdewlth air sole compensation,will do WOOD SHAKES
the work,and the structure is not Intended or offerto y ec.7044,Business and Profs-
$tans Code:The Contractor's License Lew tloae ny a an owner of property who builds or WOOD SHINGLES ❑ VYL
Improves thereon,and who does such ydork hlms tl gh his own employees,provided that V
such improvements are not Intended of off however,the building or Improvement
Iseold within one year of completion,thea It af*111 have the burden of proving that he did OTHER(SPECIFY) G\ ❑
not build or Improve for purpose of sale.). /
I,as owner of the property,am exclusivgty gun acting 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 contractors)licensed pursuant to the Contractor's License Law, PROVIDE Ili INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
O
hereby affirm under penalty of perjury one ofthe following-insure
Wo /+ / o
D have and will maintain 37a Certificate of Consent toeperforma Ion Worker's Compensation, l/(/_ '-5-9Xl Building d✓
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit ssued. rA Seismic =�
have an will maintain Worker's Compensation Insurance,as required by Section 3700 of C nO rrrr A.
the soar Code,for the pedormance of the work for which This permit 19 issued.My Worker's .J V I
Compensation Insurance carrier and Policy number are: JJ� Total
carrier 3::&R 'e ruFt d Policy No. 5C %" Unr'tA5 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed If the permit Is for one hundred dollars(5100)or less.)
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'Compansatlon Lawe of Cell- All roots shall be inspected prior to any roofing material being
fornix. installed. If a roof is installed without first obtaining an
Date (�71ri_ Applicant 4 inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certlt�eof 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 WI th all non point
with such provisions or this permit shall be deemed revoked. source regulations.
I certify that I have read this application and Stat°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-mentlonad property for in.
spection purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
judgments,
granting of this permit,
which may in any way accrue against said City In consequence
ftSIGNATURE 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