R-4664 (2) PERMIT R_ 4664
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
180 WITHIN 180 DAYS OF PERMIT ISSUANCE OR
WITHIN
FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
1 3 9 ff � so.v ,lo L'-
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
VES ❑ R yes-I understand that a Class A
NAME /O Ji /C fE roof assembly is required.
p NO K Initial I.C.B.O.k
ADDRESS— S /Iflx"^ EXISTING ROOF COVERING
PHONE O r 3 jLQ NUMBER OF EXISTING COVERINGS Z
CONTRACTOR'S
C d TO BE REMOVED Z— TO BE RETAINED
NAME V F !
ADDRESSC TYPE OF ROOF COVERING
CITYBZIP O)`� �L S T..J f Air! ,i Al TING
este .
PHONE �t/O�� 17Z�1� lir 3 BUILT-UP ROOF ❑
NICENSE E?UMBER O ASPHALT SHINGLES20,
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES 117000)of Division 3 of the Business end Professions Code,and my license Is In full force and
effect' p WOOD SHINGLES 11License Claes G -3
a G1 LIc.Number a� /90
Data A76J ZO �/ Contractor e 41 frC C F iV S OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the follOwing reason.
(Sec.7031.5,Business and Professions Coda: Any city or county which requires a permit to
Construct,after.Improve.demolish,or repair any structure,prior to Its issuance,also requires the BUILT-UP ROOF Elapplicant for such permit to file a signed statement that he la licensed pursuant to the provisions
. 01 the Contractors Licence Lew(Chapter B(commenting with Section 7000)of Divisionthe 3 blithe
exemption
and Professions Code)or that he Is exempt therefrom and the basis for thea ant to ASPHALT SHINGLES
exemption.Anyviolationo t more
of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penally of not more then five hundred dollars(h wag): WOOD SHAKES ❑
❑I,as owner of the property,or to ded employeeswithwages as their sole compensation,will s.
the work,and the structure is not Intended ores not for seta n ow er of Business entl Profbuilds
s-
alons Code:The Contractor's Licence Lew dome not apply to an owner of prayers,who builds or WOOD SHINGLES ❑
Improves(hereon,and who does such work himself or through his own employees,improvement provided that
such Improvements are not completion,
leb n,or owner-builder
for leer.If,however,the en Of pr or proving
Is sold not bullwithinor
year of for purpose of sthe owneo-bull0erwillhave the burden of provingthat he tlltl OTHER (SPECIFY) ❑
not build or Improve far 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 Lew 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 prOjeCte
with a contractor(e)licensed pursuant to the Contractor's License Law. PROVIDE MFGR. INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION - r�,
I hereby affirm under penalty of perjury one of the following declaration: ° F; CY
❑I have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this O
permit is have
�2 O 1J9� Seismic
❑I have end will maintain Worker's Compensation Insurance,as required by Section 3700 of `79 yrs
the Labor Code,for the performance of the work for which this permit Is Issued.My Workers C J Total
Compensation Insurance carrier and Policy number are: '/ CJr
Lf/Yi-:..r..
Carrier Policy No. PEFIMITTAUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NI' —2.
(TIAs section need not be completed It the permit b for one hundred dollars($100)00)o or less.) `
1 certify that in the performance of the work for which this permit Is Issued,I shall not employ
any person In any manner so as to become sustain tom 'compensation Laws of call. All roofs shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Data MO J 20 S Applicant inspection,I agree to remove all new materials for inspection.
jtIf,after
slflcate of Exemption,uttbecome
subeclt o the Workers'Compensation provisions of the Labor Code, msforthwih comply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. source regulations.
I certify that l have read this application and state that the above Information is correct.I agree
to comply with all city and county ordinance$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 she above-mentioned property for In.
spectiherebon purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
. costs and
we which may In any way accrue against mltl Cl.,In Consequence
e granting of this permit. SIG ANT 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