R 4994•
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OFFICE COPY
PERMIT R_ 4994
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
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
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I ` C t/t e I.
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RESIDENTIAL COMMERCIAL OTHER
OWNER'S
I HAZARDOUS FIRE AREA
YES ❑ If yes -1 understand that a Class A
NAME n V \ I J ✓x^ '�
roof assembly is required.
NO - Initial I.C.a.O, N
S �A
I C P
EXISTING ROOF COVERING
ADDRESS I v l C w �� V C <-t
r PHONE Ok 'J
NUMBER OF EXISTING COVERINGS
TO
BE REMOVED_ TO BE RETAINED
CONTRACT R'S -
NAME �
P o -L
IYJE OF ROOF COVERING
�TYBZIP ► �� x 1u Z ? c�
EXISTING
�_'rI , 1 t0 , J
q ' �� 1 _I
PHONE
BUILT-UP ROOF
LICENSE
NUMBER
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter g (commencing with Section
WOOD SHAKES ❑
7000) of Division 3 of the Business and Professions Code, and my license Is in full force and
effect..
C -
WOOD SHINGLES ❑
License Cle Lie. Number3r
'• ,
WC
OTHER (SPECIFY) ❑
Data Contractor
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
PROPOSED
(Sec. 7031.5, Business and Professions Code: Any city or cc which requires a permit to
construct, alter,Improve,demolish, or repair any structure, prior t Sjisuance, also requires the
BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is Iicens au suant to the provisions
of the Contractor's License Law (Chapter g (commencing with Soft I of Division 3 of the
Business and Prolesslons Code) or that he Is exempt Thera rom it th ale for the alleged
ASPHALT SHINGLES
exemption. Any violation of Section 7031.5 by any Spell afore t It W01e aapplicant to
e civil penalty of not more than five hundred tlollere
❑I, as owner of the property, or my amployeeaWith we their sole compensation, will do
WOOD SHAKES ❑
the work, and the structure is not Intended or red I Is (Bac. 7044, Business and Profits.
slons Code: The Contractors License Lew nIgen owner of property who builds or
improves thereon, and who does such w hl 1 r rough his own employees, provided that
WOOD SHINGLES ❑
such Improvements are not Intentletl or o to I. however, the building or Improvement
Is sold within one year of completionthen If or III have the burden Of proving that he did
OTHER (SPECIFY) ❑
not build or Improve for purpose of e9lie.).
❑ h 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 project.
with a contractor(a) licensed pursuant to the Contractors License Law,
❑ I am exempt under Sec. ,B & P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner Date
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE VALUATION
PERMIT FEE
I hereby affirm under penalty of perjury One of the following declaration:
❑ I have and will maintain a Certificate o1 Consent to self -insure for Workers Compensation.
as provided for by Section 3700 of the Labor Code, for the performance of the work for which thle
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0 ^ nn 4 i
Building
permit Is Issued.
❑ 1 have entl Worker's Compensation Insurance,
I f c.A
A I ? �P
Seismic
will maintain as required by Section 3700 of
the Labor Code, for me performance of the workfor which MIS permit Is Issued. My Workers
1
���� s Jnr
Compensation Insurance carrier nr numb are: O� o' 2'q Z-9
--ie ✓ri a w-1ff�/
o
Total
- p RMIT AUTHORIZATION
DATE
Carrier Poocy Na
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(TMs 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
All roofs shall be Inspected prior o an i ofin a ' I being
any person In any manner so as to becom act to the Workers' Compene@11 n s of ti-
!T. 7 n7 6tom. J\
installed. If a roof is installed without first obtaining an
Date 6 Applicant.
Inspection, I agree to remove all new materials for inspection.
ou shoulecome
subje�toEthe Workers' Compelnsation provisioTO APPLICANT, 1, after makinns of thelLaborr Code, yolu ms Certifcate of Exempton, ustforthwitlhbcomply
Applicant understands and will comply with all non point
with such provisions or this permit shell be deemed revoked,
I certify that I have read this application and State that the above Information Ie correct. I agree
to comply with all city and county ordinances and state laws relating to building construction, and
Source regulations.
All roof coverings to be class "C°or better.` 1
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
I
spection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities,
Judgments, costs and expenses which may In any way accrue against said City Inconsequence
of the granting of this permit.
SIGNATURE OF APPLICANT DATE
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