R 4594•
•
F_I
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OFFICE COPY
PERMIT q_ 4594
APPLICATION FOR 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
' 1 SO DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
13 C 7 FIOa2 DGS
o2,
RESIDENTIAL COMMERCIAL OTHER
OWNER'S ` .
HAZARDOUS FIRE AREA
/rr „ �e "T77 x
VES ❑ if yes — understand that a Class A
NAME - f.�!!�r ' r
NO roof assembly is required.
tial LC.B.O. #
2! 3 G % M &7*A_yA VA
I EXISTING ROOF COVERING
ADDRESS
PHONE 11F3o
NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
•
NAME d�►L
TO BE REMOVED TO BE RETAINED
IYPIE OF ROOF CQY
ADDRESS
CITY & ZIP
EXISTING EXISTING j
PHONE
BUILT-UP ROOF ❑
LICENSE
NUMBER
ASPHALT SHINGLES /
❑
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I In affirm that I am licensed under provisions of Chapter 8 (commencing with Section
7000) rt Division 3 of the Business and Professions Code, and my license Is In lull force and
effect.
WOOD SHINGLES
j
License Class LIc. Number
OTHER (SPECIFY) ❑
Date Contractor
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Lew for the following reason.
PROPOSED
(Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to
construct, alter, improve, demolish, or repakany structure, prior to Its Issuance, also requires the
BUILT-UP ROOF 1:1applicant
for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractors License Law (Chapter g (commencing with Section 7080) of Division 3 of the
Business and Professions Code) or that he Is exempt therefrom and the basis for the alleged
ASPHALT SHINGLES
�T
exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a d nalty of not more than five hundred dollars ($500).):
WOOD SHAKES
owner of the property, or my employees with wages as their sole compensation, will do
th work, and the structure Is not Intended or offered for sale (Sec. 704, Business and Profes.
sl aCode:TheContractor'sLicenseLawdoesnotapplytoanownerofpropertywhobuildsor
Improves thereon, does himself
WOOD SHINGLES ❑
and who such work 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 ownOr-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 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 contractors) licensed pursuant to the Contractor's License Lew.
01 em exempt under Sec. ,B & P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner Date
WORKER'S COMPENSATION DECLARATION
1. APPLICATION DATE
VALUATION
PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
Fj
❑ 1 have and will malmain a Certificate of Consent to self -insure for Workers Compensation,
as provided for by Section 3700 o1 me Labor Code, for the performance of the work for which this
permit Is Issued.
psswp..^
�`r
I _ 20
Building
❑ 1 have end wlll maintain Worker's Compensation Insurance, as required by Section 3700 of
the Labor Code, for the performance of the work for which this Is Issued, My Worker's
h
�// t� 199,g
J9
' 2O/s�
Seismic i
permit
Compensation Insurance carrier and Policy number are:
�h `Lir
6e{j
Total
J
Carrier Policy No.
PERMWAUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 1.0)
C-
(Thio section need not be completed the permit Is for one hundred dollars ($100) o
or 1866.)
1
I certify that In the performance of the work for which this permit Is Issued I shell not employ
All roofs shall be inspected prior to any roofin material being
any person In any manner so as to become subject to the Workers' Compensation Laws of Call.
tome.
installed. If a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
subject to the WorrkereTICE TO s'Compelnsetlon making
of the "bar Code you musufoinwll shouldbecame
comply
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 correct.I agree
to city
All roof coverings t be class "C"or bene
hereby uthoriell
repesecountyordinancesendteruponhelatingto entingconatructlogan0
hereby authorize representatives of this city to anter upon the ebpvementlonetl property for In-
spection purposes.
(We) and keep harmless
(We) agree to save, the City of Cupertino against liabilities,
expenses was
coats and expenses which may In any way accrue against said City In consequence
at the granting
oohs granting onhi6 permit.
SIGNATURE O APP SANT DATE
PRE -INSPECTION:
PLYWOOD: -
ROGRESS:
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