R-4621 APPLICATION FOR CITY OF CUPERTINO
NUMBER PERMIT
R- 4621
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
BUILDING ADDRESS
1B0 DAYS FROM LAST CALLED INSPECTION.
.
RESIDENTIAL COMMERCIAL OTHER
OWNER'S , HAZARDOUS FIRE AREA
NAME C IN Dom( 6Q/� YES ❑ If yess I assembly
is required. Class A
roof assembly is requiretl.
NO ❑ Initial I.C.B.O.k
ADDRESS YY8 O��PS 1 C� / i UE EXISTING ROOF COVERING
PHONE Sia 77D.- 0-36'Z— NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S
e6l-re-n S F� D� _ / / AJ` TO BE REMOVED TO BE RETAINED
NAME Jf !�/n�/ /�.(1�. /�'
ADDRESS (�30S-S- S C OOc�/ f"cX I��+�h'� TYPE OF ROOF COVERING
CITY&ZIP
9U�1 EXISTING
PHONE Seo J 70 3 •'� BUILT-UP ROOF ❑
LICENSEY g ASPHALT SHINGLES
❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am 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
affect.
_ �&WS �� WOOD SHINGLES qq ❑
License Class Lic.Number � 4'i 8 RT
Date Contractor
V
OTHER(SPECIFY) �y def'
7
OWNER-BUILDER DECLARATION PROPOSED �/ . T 1 0 �9
1 hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to 0�.
v
construct,alter,improve,demolish,or repair any structure,prior to Its issuance,also requires the BUILT-UP ROOF uh C(/p ❑.
applicant 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 �f YY0
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES Elexemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of not more than five hundred dollars($500).):
❑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 peered for sale(Sec.7044,Business and Promi
.lensCotle:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES
improves thereon,antl 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 n
is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) � D(.tRh CLYE
not build or improve for purpose of sale.).
I,as owner of the property,am exclusively contracting with licensed contractors to construct n
the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO. 20
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 MFGR.INSTALLATION SPECS.
E]I am exempt under Sec. .B 8 P.C.for this reason
Owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
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, Building Do""'
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this /0
permit Is Issued.
I have and will maintain Workers Compensation Insurance,as required by Section 3700 of �-/ q6.
�^ Seismicc
,the Labor Code,for the performance of the work for which this permit is issued.My Worker's c Total
compensation Iusura�nrcle car(r'�/5antl�Pq(Iycy number are:
carrier f '�t"J ` �"' "� Policy No,N W L"51'M`7 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need not be completed it 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 parson in any manner so as to become subject to the Workers'Compensation Laws of Cali- 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.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non pint
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP P Y P
with such provisions or this permit Sheri deemed revoked. source regulations.
I certify that 1 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 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.
(Wal agree to now,indemnity and keep harmless the City of Cupertino against liabilities,
• judgments,costs and expenses which may In any way accrue against sold City In consequence IGN RE APPLICANT DATE
of the granting of this permit.
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