R-4575 APPLICATION FOR CITY OF CUPERTINO
NUPE BER R- 45
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
ISeti AS'}¢,- La '3 1.4 RESIDENTIAL_COMMERCIAL OTHER
OWNER'S /_ HAZARDOUS FIRE AREA
NAME I6A\-*\cK POLk JCAkl ! -1MR5 SES ❑ is is admired.nd that ClassA
roof assembly is required.
NO ❑ Initial LC.B.O.k
ADDRESS 11r>_(:F Iks4el" "W's— EXISTING ROOF COVERING
PHONE 77-7— g'Z NUMBER OF EXISTING COVERINGS (
CONTR CTOR'S
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS ^ F L TYPE OF ROOF COVERING
CITY&ZIP K39���' OCA P� 01/
/��- \ —� EXISTING
PHONE (5�A 1 1 �1 CJ's �o�� q
BUILT-UP ROOF ❑
LICENSE
NUMBER
LICEASPHALT SHINGLES E]NSED CONTRACTORS DECLARATION p
I hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES 9 y
7000)of Division 3 of the Business and Professions Coda,and my license is In full force and
effect' e WOOD SHINGLES ❑
License Class ^ Lic.Number
Date Cont ContractorNR� OTHER(SPECIFY) ❑ -
OWNER-BU DER Contra RATR7f�'� PROPOSED �
hereby affirm that I em exempt from Co Contractor's License Lew for the following reason. .f (y
(Sea 7ct,alt Business and Profedemolish,
ore Code: Any city or county which re,also requires permit to I
construct,alter,Improve,to file signed sta any he prior to lis issuance,to theprvi the BUILT-UP ROOF ❑
applicant for such permit to flaw a signed statement that he is licensed pursuant to the pro of the � �,^ IA--
of the Contractor's License Law(Chapter 8(commencing with Section 7000)of Division 3 of the �„ 1-^c.
Businessptio and violation of Code)or that he is exempt therefrom and the bases for the applicant
to ASPHALT SHINGLES ❑
exemption.Anyviolationelhanfen7031.8byanyapplicantfora permit subjects the eppllceni io 6�x eHs
e civil penalty of not more than five hundred dollars(h wag): WOOD SHAKES
❑1,as owner of the property,or tmy eemployeeswith wages as their sole compensation,will do ❑
the work,and the structure Is not Intended ores not
for sale(Sac.7044,property
and builds
o-
siers Cotla:thereon,
Contractor's License Lew does s not apply to an owner of property who provided
t or WOOD SHINGLES ❑
improves thereon,end who does n such work offered
himself or through his own employees,doingor improvement etl that
such Improvements are not Intended or offered for sale. ill however,the building o i improvement
ntbuild or
improve
for purpose of
sale.).
owner-builder will have the burden of proving that he did OTHER(SPECIFY) Rr
not build or improve for purpose of sale.). p
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct 37A(8
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 Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 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: P,0
❑I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, Building o
as provldad for by Section 3700 of the Labor Code,ler the performance of the work for which this /� , �`_
permit le Issued. Seismic 0
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of �0�, ��
the Labor Code,for the performance of the work for which this permit Is issued.My Worker's
. �Compemraatiioro(nnszurhanceccaarriieerandPolicynumberare: 17
TOtaI
Carrier k�'Mv—"�"ter `�lL Policy No.OWL3170 PERMIT AUTHORIZATION DATE
CERfIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.(]
(This section need not be completed If the permit is for one hundred dollars(5100)or lass.) �.uC �r �/L,�t`yk•`G.G' 'I /
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 subject to the Workers'Compensation Laws of ea8- All roof^shall be inspected prior to any roofing material being
fornix. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materialsforsinspection.
NOTICE TO APPLICANT: If,akar making this Certificate of Exemption,you should become Applicant understands and will It It ; non
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP comply P Y POmt
with such provisions or this permit shalgbe deemed revoked Source regulations.
I certify that I have read this application and state that the above Information Is correct.I agree }� 2 21995
to comply with all city and county ordinances and stela laws relating to building construction,and OVefmg aSS'"C"ofl�tlrr.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection
mspection purposes. L
(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 sold City In consequence
of the granting of this permit. SIGNATbRE-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