R-4651 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 4651
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 .. PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
r
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
� 98'/f Ofa- �//[i/ti AIIjIP/\••✓'•i'o'"at—�• `
•RESIDENTIAL- X COMMERCIAL - OTHER
OWNER'S o HAZARDOUS FIRE AREA
YES ❑ tt yes-I understand that a Class A
NAME roof assembly is required.
- - NO Initial I.C.B.O.is
ADDRESS EXISTING ROOF COVERING
PHONE
C NUMBER OF EXISTING COVERINGS /
Z S,rj � � -
CONTRACTOR'
NAME
TO BEREM OVED TO BE RETAINED
� /��J72��!�J ✓w � ,
ADDRESS TYPE OF ROOF COVERING
.CITY&ZIP 90 �?fi1.Gi r ALT//[Gly N/r�-^-e
(j EXISTING
PHONE O aO ��� — 7 411 - BUILT-UP ROOF . - ❑ -
LICENSE -
NUMBER C ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that i am licensed under provisions of Chapter 9(commencing with Section WOOD SHADES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is in full force and -
effect. WOOD SHINGLES ❑
License Class � � Lla Number 6 86 6 -
L y _ OTHER(SPECIFY) ❑
Data Contmcto
OWNER-BUILDE DE LARATION PROPOSED I hereby affirm that I am exempt from the Contractors License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,alter,Improve,Carl or repair any structure,prior to its issuance,also requires the BUILT-UP ROOF % Q4 Elapplicant for such permit to file a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the r > c
Business and Professions Code)or.that he is exempt therefrom and the basis for the alleged ASPHALT SI IIq&
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to LUN e�
a civil penalty of not more than five hundred dollars($500).): WOOD SHAKES
❑I,as owner of the property,or my employees with wages as their sole compensation,will do \ qLl
the work,and the structure is not Intended or offered for sale(Sec.7044,Business antl Profen-
' 'sions Coda:The Contractor's License Law does not apply to an owner of property who builds or OD SHINGLES
improves thereon,and who does such work himself al.If,ho his own em building
s,pravltletl that ❑
such improvements are not Intended Or work
himself
for sale.If,however,the building or Improvemanl
issotd within one year of completion,the owner-builder will have the burden Of proving that he did OTHER(SPECIFY)
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed convectors to construl j
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not' PROVIDE I.C.B.O.REPORT NOi
apply to an owner of property who builds a r improves thereon,and who contracts for such projects
with a contractors)licensed pursuant to the Contractors License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&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:
-11 have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, - BUlldin
perits Is for by Section 3700 of the Labor Code,for the performance of the work for which this / / // ��� —
per is Issued. , /f,� Seismic ��11.�`/S�J�
I have and will maintain Workers Compensation Insurance,as required by Section 3700 of {{{ /
e Labor Code,for the performance of the work for which this permit is Issued.My Worker's '
'Compensation� Inpsurance carrier and Policy number are: ^ p - Total
Carrier l9�Cwere'lli 15l - Policy NOI 7 11� PERMIT AUTH N DATE
-.
CIERTIFICAIrE OF EXEMPTION FROM WORKERS' '�
` COMPENSATION INSURANCE N.CQ ki I'll
This section need not be completed If the permit is for one hundred dollars($100)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'Compensation Laws of Cell- All roof^shall be inspected prior to any roc ng 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.
NOT CE TO APPLICANT: If,after making this Certificate of Exemption,YOU Should become Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply P Y P
with such provisions or this permit shalQba deemed revoked. source regulations.
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 All roKfer' tobe lass"C"or better.
hereby authorize ropresentatives at this city to enter upon the above-mentioned property for In-
spection purposes.(We)agree to save,indemnity antl keep harmless the Cityof Cupertino against liabilities,
jutlgments,costs and expanses which mey in any way accrue against Sold City in consequence
of the granting of this permit. SI NATUFI OF APPLICANT DATE
• PRE-INSPECTION: PLYWOOD: _ IN-PROGRESS: `
INSP.—DATE INSP. DATE If DATE
TEAR OFF INSPECTION: BATTENS: - FINAL:
INSP.. DATE INSP. DATE INSP.' - DATE
NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION'
OFFICE COPY