R 4922 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 4922 .
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
6 30 ` ✓ ���� ,p RESIDENTIAL E COMMERCIAL OTHER
OWNER'S / HAZARDOUS FIRE AREA
�14 �-�� YES ❑ It yes-I understand that a Class A
NAME ` n f assembly is required.
L / NO Initial C.B.O.#
ADDRESS-/dG 3�T r D 6 KO ��i� Cf EXISTING ROOF COVERING
PHONE 7 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME /rte-.,r{/ �(�y//L7VG� TO BE REMOVED TO BE RETAINED
ADDRESS �2 Z l����� �/ , TYPE OF ROOF COVERING
CITYBZIP - !-� 0TH/_e
EXISTING
PHONE "� �C( �7 BUILT-UP ROOF ❑
LICENSE
NUMBER 3 ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
hereby affirm that I em Business
under erosions of e,and 8(commencing with Section and WOOD SHAKES
7000)of Division 3 of the Buflinees entl Professions Code,entl my license is In lull force entl
affect. WOOD SHINGLES ❑
License Claes Lic.Number
Onto —Z -dr,omractor OTHER(SPECIFY) r ❑
OWNER-BUILDER DECLARATION PROPOSED G1 r7
I hereby affirm that I em exempt from the Contractors Licen a Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or c ty which requires a permit to �Inq
construct,alter,Improve,demolish,or repair any structure,prlor to Issuance,also requires the BUILT-UP ROOFWAr '30 ' ❑
applicant for such permit to file a signed statement that he a lice d purer ant to the provlalona xa
of the Contractor's License Lew(Chapter a(commsnclnoy with S9 00d)J of Division 3 of the (tf,. `xf
• Business and Professions Code)or that he Is exam therafrtf"I the tle9Is for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031,5 by any appl adt for a pe I ubl cts the applicant to V
a civil penalty of not more than five hundred dollarp(S )J: Irk,I f rry�
I]1,as owner of the property,or my employee(with as t e e compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended y(offsropr e 044,Business and Protea.
alone Code:The Contractor's License LeWtl 'no OP., at ofproperty who builds or WOOD SHINGLES
Improve$thereon,and who does such w6rk entl Is n employees,provitletl that ❑
such Improvements are not Intended o f -B e. waver,the building or Improvement
is sold within one year of completion,t r. have the burden of proving that he did OTHERSPECIFY
not build or Improve for purpose of OTHER(SPECIFY) ❑
❑I,as owner of the property,e(ri a Q mclln with licensed contractors to construct
the project(Sec.7044,Business and P eeio ode:The Contractors License Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who bull y714e thereon,and who convects for such projects
with a contmctons)licensed pursuant o th1l.Cbntmctors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 em exempt under Sec. ,B 8 P.C.for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to sell-Insure for Workers Compensation,. Building
provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit lave and / r ^Q 0, 6 0 Seismic
have entl will maintain Worker's Compensation Insurance,as re t Is I by Section 3700 of (J !J C)./b_/
the Labor Cod r or the performance of the work for hlch Ihle er It Is Iseuetl,My Worker's
Compensatl Insurance r randP�number re: IC9 6� pO�ro� Total
carrier PoucyNo. Z L PERMITAUTHORIZATI DATE
CERTIFICATE OF EXEIMPTION FROM WORKERS'
COMPENSATION INSURANCE N.OI]
(This section need not be completed It the permit Is for one hundred dollars($100)or lase.)
1 certify that In the performance of the work for w eh this permit Is Issued,1 shell not employ
any person In any manner so as to become subj the Workers'Comp nsation Laws of Cell. All roofs Shall tie inspected prior to any fin erial being
forma.
� p/ installed. If a roof is installed without first obtaining an
Data d L Applicantinspection,lagree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Examptilln.you should become
subject to the WoMare Compeneetlon provisions of the Labor Cotle,you must forthwith comply Applico understands and will Comply with all non point
with such provisions or this permit shall be deemed revoked. Sour r ulations.
I certify that I have read this application and state that the above Information le correct.I agree
to comply with all city and county oMinencee and eters few$relating to building conatructlon,antl All r Of eri S I be class"C"or better.
hereby authorize ropresentadvee of this city to enter upon rho above•menfiched property for In.
ep We) purposes. CityCupertino
(We)puree to save,indemnity and keep harmless the CI of egelnet Ilebllltlee, 7`
judgments,costs and expenses which may In any way accrue against said City In consequence
of the granting of'.� PRE-INSPECTION:
PLYWOOD: SIGNATURE O DATE
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