R-4663 APPLICATION FOR CITY OF CUPERTINO
NUMBER R— 4663
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 160 DAYS OF PERMIT ISSUANCE OR
BUILDING ADDRESS
180 DAYS FROM LAST CALLED INSPECTION.
Q�I l 1 I'
1,5-7-7 "V� `-'x— - RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
JO r I r I �,id,p. p S u�� VES ❑ If yeas I assembly
is req that. Class A
NAME 1'�N' r""'7 of assemlNy is required.
/�r�liNO Initial LC.B.O.#
ADDRESS— t!5-1-i ' ' :x— EXISTING ROOF COVERING
PHONE 4,l,'Z,6_2-Z) NUMBER OF EXISTING CO RINGS I
CONTRACTOR'S
NAME + `�•'ok—C4ki— �LOOIrlt`44 TO BE REMOVED TO BE RETAINED
ADDRESS S3 � TYPE OF ROOF COVERING
CITY&ZIP
2 V 2 EXISTING
PHONE ✓�o�JZZZ BUILT-UP ROOF ❑
CENSE
NUMBER COZY' bZ3 ASPHALT SHINGLES ❑ -
LICENSED CONTRACTORS DECLARATION
hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license is In full force and
affect. WOOD SHINGLES
License Class Up.Number
Data Contractor OTHER(SPECIFY) ❑
OWNER BUILDER DECLARATION PROPOSED
1 hereby affirm that I am exempt frch the Contractors License Law for the following reason.
(Soo.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,alter,Improve,demolish,or repair structure,prior to Its issuance,also requires the BUILT-UP ROOF ❑
as
for such permit to lila apigned state nt that he is Ilc ed pursuant to the provisions
of the Contractor's License Law4,Chapter 6 a mencing with 7000)of Division 3 of the
Business and Professions Code) ih h Is xampt tr en the bests for the alleged ASPHALT SHINGLES ❑
exemption.Any violation of Sectio 3 m ep II m r p r subjects the applicant to
e civil penalty of not more than five n d donors WOOD SHAKES❑I,as owner of the prope or a so$witth as as their sole compensation,will do ❑
the work,enyonu
t inten ad or flejaB f r Is(Sec.7044,Business and Proles-
slonsCotle: aLicense aw not apply to en owner of property whobuiltlsorWOOD SHINGLESImproves thetloes suchr self or through his own employees,provided that
such improventended or here for sale.ll,however,the building or Improvement '346-Wn6RfJ,illZIs sold within mpletion,the owner-builder will have the burden of proving that he did OTHER (SPECIFY) d�t�-��/�OrVK�not build, iose of sale.). �1
I,as owner of the property,em exclusively contracting with licensed contractors to construct T 1.f/
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 contractor(s)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:
❑l have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, rVo� Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this 6 1xk
permit Is Issued. O y♦ 5�� 0� $gIBmIO
I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
.the Labor Code,for the performance of the work for which this permit is issued.My Worker's C)f y
Compensation Insurance carrier and Policy number are: Ur txUrtH))ji � TOtal
Carrier S� r two Policy No. )S191,69--95 31ZAfION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.(:]
(This section need not be completed If the permit Is for one hundred dollars($/00)or less.)
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'Compensation Laws of Cali. All roofs she be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
come
Subject to the Workers'Oo Compensation p 11,after ro making
ls ofethellcate of Labor Code,Exemption,
mustforthwithlcempty Applicant understands and will comply with all non point
with such provisions or this permit shal@be deemed revoked. Source regulations.
I certify that I have read this application and state that the above Information Is correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof c sto be class"C"„pr better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In. 1= 1 I'I�/ 9,
hereby
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 In consequence SIGNATURE OF APPLICANT DATE
of the granting of this permit.
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