R-4573 aPERMIT R_ 4573
LIC OR CITY OF CUPERTINO NUMBER
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
O.- -C- /:JJs \ &2_ RESIDENTIAL_ COMMERCIAL OTHER
OWNS s-�(J / '�T HAZARDOUS FIRE AREA
NAME L/ y ! Ag ,:0 C-- YES ❑ It yeas I understand that a Class A
y P� �U-1 root assembly is required.
NO InitiI I.C.B.O.If
• ADDRESS�'3� "�'"1- s� ` EXISTING ROOF COVERING
r
PHONE `IiS — e3 d NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
f� TO BE REMOVED TO BE RETAINED
NAME al - S /fie -..�� TYPE OF ROOF COVERING
CITU 8 ZIP-
ADDRESS �1 /J�f� 3C}Q3 � /��,
�J /S T (/
XI ING
PHONE�SlO� ���' Y/8 Yod BUILT-UP ROOF ❑
LICENSE
NUMBER y7 /OI� ASPHALTSHINGLES ❑
_. LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions 01 Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full torte and
effect. n t/ WOOD SHINGLES ❑
' License Class Lic.Number S' r
'
Date ,/, contractor OTHER (SPECIFY) E]
OWNER-BUILDER DECLARATION 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,demolish,or repair any structure,Crate its Issuance;also requires the BUILT-UP ROOF '❑
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
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
❑I,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 offered for sale(Sec.71 Business and Profes-
sions Code:The Contractors 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) ❑
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 Contractors 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 contradOr(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
r-1I am exempt under Sec. ,B&P.C.for this reason
Owner Date 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 Workers Compensation, �.A BU td'
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. C// 19gr -seismic
`�+k,ve and will maintain Worker's Compensation Insurance,as required by Section 3700 of VP "7Q0-
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's LU /
Compensation�Insuranccee carrier and Policy nuangor are: y C Q �L, 11y6 Z Total
15;Carrier--. < F4✓L/-1 Policy No. L?`5 —TT- e,4 PERMIT AUTHORIZATION DAAE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed if the permit is for one hundred dollars($100)or Is".) I
I certify that In the performance of the work for which this permit Is issued,I shall not employ
any person In any manner so as to become subject to the Workers'Com ynsabon Laws of call- All roof^911rall be Inspected prior to any rooting material being
fornia. _ _ installed. If a roof is installed without first obtaining an
DataApplicant inspection,I agree to remove all new materials for inspection.
NOTICE subject to the Workers*Compnsati n provisioT. Ir,shot anni ns of the Labor Code,s Certificate of Exemption,
oiu m�uforthwlitthacanne
omply Applicant understands and will comply with all non point
with such provisions or this permit ehelQbe deemed revoked. Source regulations.
I certify that I have read this application and state that the above Information Is correct.I agree 01
to comply with all city and county ordinances and state laws relating to building construction,and All to coverings b ss"C"or better.
hereby authorize representatives of this city to anter upon the above-mentioned property for in.
spection purposes.
(We)agree t0 save,expenses
which
keepmay I harmless the Cly a of Cupertino against liabilities,
judgments,costs and expenses which may In any way accrue against sem City Inconsequence I$GNATURE OF APPLICANT ATE
of the granting of this permit.
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE rINSP. 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