R-4950 (2) PE
APPLICATION FOR CITY OF CUPERTINO NU BER R- 4950
REROOF PERMIT INSPECTION DIvISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
/0"3 1619 as- eqk
.p RESIDENTIAL COMMERCIAL OTHER
OWNER'S��/� y/ HAZARDOUS FIRE AREA
NAME `"'--'��N J��1 /�/�yp9�� YES ❑ If yes—I understand that a Class
roof assembly is required.
' NO ❑ Initial I.C.B.O.#
ADDRESS— gve it 9,,eryU EXISTING ROOF COVERING
PHONE �' �� % S� NUMBER OF EXISTING COVERINGS
CONTRACTORR,'$ p
NAME /`O t-J/� / /l0 0 l/xL.X4 TO BE REMOVED TO BE RETAINED
CDTDY
ADDRESS
5C,0 Al /b �� Jr �,� �4 TYPE OF ROOF COVERING
EXISTING
PHONE '7'ed? • .�?83 -2./ r 1 —/
BUILT-UP ROOF
LICENSE
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license is in full force and
sped. C �f /�S-• — WOOD SHINGLES /
License Class Lic.Number ` 7
Date /
6//9/yc Controctor i+ oph�L y OTHER (SPECIFY) 1:41&,04
OWNER- An DECLARION i
PROPOSED
1 hereby affirm that the Conam exempt from the Contractor's License Lew for the following reason.
(Sec.70315,Business and Professions Code: Any city or county which requires e permit to
consapplicant for
er,such
improve,demoto file Signed air any statementrthate,prior to its Issuance to also
the BUILT-UP ROOF
applicant for such permit a lila a signed statement that,% Is licensed pursuant to the provisions
of the Contractors License Lew(Chapter 9 1.ex encing with Section 7000)of for the 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 healon 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than live hundred dollars($800).):
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES
the work,and the structure is not intended or offered for sale(Sec.7044,Business and Profes.
sions Cade: The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES
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 proving that he did OTHER(SPECIFY) ED
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting 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 contractor(s)licensed pursuant to the Contractor's License Law, PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. B 8 P.C.for this reason
Owner APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to self-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 Ih 6 g
permit is issued,
l✓/ l , Seismic leave
❑ have end will maintain Workers Compensation Insurance,as repulsedsu d.My
3700 0l
the Labor Cade,for the performance of the work for which this permit Is issued.My Worker's
Compen tion Insurance carrier and Policy nugiber are: Total 22,211,
carder 0L0L 0 A4N('fr-1 Pokcy No.35-) PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEM ION FROM WORKERS'
COMPENSATION INSURANCE N.C.I]
(This section need not be completed If the permit is for one hundred dollars($100)or lass.)
i certify that in the performance of the work for which this permit Is IssueQ 1 shell not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Cell. All roots shall—be inspected pri any roofing material being
forma. installed. If a roof is instaligg without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOT CE
subject IS theOWorkers'Compen
satio provisions ofetheiflLatborr Code,yolu mrrust forthwitlhbcomply 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 correctI 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.
spection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may In any way accrue against said City in consequence
of the granting of this permit. SIGNATURE OF APPLICANT DATE
PRE-INSPECTION:
E-INSPECTION: PLYWOOD: IN-PROGRESS:
yINSP. 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