R 4767 (2) PERMIT
APPLICATION FOR CITY OFCUPERTINO NUMBER
R 4767
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK 19 NOT STARTED
WITHIN PERMIT ISSUANCE OR
WI DAYS
FROM
LAST CALLED INSPECTION.
BUILDING ADDRESS
Q S A—U Q RESIDENTIAL_E COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
t�^ x \ VES C) 11 yes—I understand that a Class A
NAME) !'_` �• �� ��1 U J f( :`1, YES
assembly is required.
NO Initial -LC.B.O.s
ADDRESS ( OS'2 S_I b kCAa AuQ EXISTING ROOF COVERING,
PHONE
NUMBER OF EXISTING COVERIN I
CONTRACTOR'S
AAME W R'Cr/� E YC., TO BE REMOVE TO BE RETAINED
ADDRESS (� O r7jS.S eT' J �IICJAr 91,W103A I^,L1
CIN&ZIP- l� �'D EXISTING
PHONE g 3�) BUILT-UP ROOF ❑
LICENSE X07 2 q•Z,. CO ASPHALT SHINGLES dZ.❑ /
NUMBER
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provlelons of Chapter B(commencing with Section WOOD SHAKES \
7000)of Division 3 of the Business and Professions Code,end my license Is In full force and
effect. ^' WOOD SHINGLES ❑
License Claes �_ �� U,Number 5 ZD
I t LS--9 1. OTHER(SPECIFY) ❑
DateZV
Contractor
OWNER-BUILDERqDTCLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the 1 >.I.ng reason.
(Sec.7031.5,Business and Professions Code: Any city or county which rep res permit to
construct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to IIIe a signed statement that he Is licensed pursuant to the provisions
• of the Contractor's License Law(Chapter a(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES ❑
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500).): WOOD SHAKES
❑1,as owner of the property,or my employees with wages as their sole compensation,will do ❑
the work,and the structure Is not Intended or olore or sale Sec.7044,Business and Profes.
some Code:The Contractors License Law dose n apply to n owner of property who bulltle or WOOD SHINGLES f
Improves thereon,and who does such work trims or throu his employees,provided that 42, �.�
such Improvements ere not Inlentled or oNe I sale.ll, waver a building or Improve man, ✓
Is ntoowithln ane year of compledon,theo uloerwI eve th It of that he tlld OTHER(SPECIFY) �—
not build or Improve or purpose al eeleJ'❑I,as owner of the propertyem exclu iv. contra nBw a atoll contractors to construct
the project Sec.7046,Buelnees and Profeealane Code:The on tor.Llcenee Lew does not PROVIDE LC.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.License Lew. PROVIDE MFGR.INSTALLATION SPECS.,
[DI am exempt under Sec. ,B 6 P.C.for this reason .
Owner Dale APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby alllrm under penalty of perjury one of the following declaration:
j ❑I have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, BUIIdm
as provided for by Section 3700 of the Labor Code,or the performance of the work for which this g
perm) anddedIl,�;el rp g ����
I e and will the performance
rmancWorkers Compensation Insurance,as required by Section 3700 of •" G V $elSrrllC
` th or Colla,for the pedormence of the work for which this permit Is leeuetl.My Worker's7 /'1�
'Compeneatlon Insurance terrier and Policy number are: CI'I r ulip'l-14 111119 ` Total
Carrier ' � PollcyNo. (e/G/N�OfTrr PEqK4rr AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS �\
COMPENSATION INSURANCE N.C.I]
(This section need not be completed If the permit Is for one hundred dollars El 00)or lees.)
I certify that In the performance of the work for which this permit is leeuetl,I shall not amtoy
any person In any manner so as to become subject to the Workers'Compensetlon Laws of Sell. All roofs shall be Inspected prior to any roofing material being
forma. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
ecome
subject o the Workers'Compensation proviCE TO APPLICANT: If,after e ns of the LebItertIfica o oceExemyotu mustforthwith lbcomply Applica dersta ds and will comply with all non point
with such provisions or this permit shalPim deemed revoked. Sour regulation
I certify that I 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 building construction,and roof Cover s 7to "C"Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property or In.
ep(We) purposes.
(We)agrees neve,Indemnand expenses
and keep by way the City of Cupertino ap con liabilities,
. ofthe granting of this perrmiL ea which may In any way accrue against said Clry In consequence NATUR O A15PLIC DATE
PRE-INSPECTION: PLYWOOD: IN-PRO SS:
INSP. DATE INSP. DATE IN DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE Cn PY