R 4886 PERMIT q_ 488
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APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 160 DAYS OF PERMIT ISSUANCE OR
• 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
1065'5 RESIDENTIAL--Z
COMMERCIAL OTHER
OWNER'S I^ HAZARDOUS FIRE AIR
Cho )J YES ❑ If yes-I understand that a Class A
NAME roof assembly is required.
NO ❑ Initial I.C.B4O.R
ADDRESS_I1yil IS Q ��a ty EXISTING ROOF COVERING
r
PHONE ! 7-( (e-5 ' NUMBER OF EXISTING COVERINGS I
CONTRACTOR'S
�/1/1 DEO, /I.. A h ' TO BE REMOVED TO BE RETAINED
�
NAMEMZ L� V LS.0-l�Y
ADDRESS . n n TYPE OF ROOF COVERING
CITY&ZIP �6 '-t0. A A A4 Laku ba .Q..Q
m
2/�
PHONE u'�+'1-7qL' 0 BUILT-UP ROOF ❑
LICENSE (�/]�/1.�
NUMBER CJ OO ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
hereby affirm that I em licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
700 0)of Division 3 of the Business and Professions Code,and my license Is In full farce and
effect' WOOD SHINGLES ❑
License Cleas ` Lie.Number
Date ^3 contractor OPE Dl • OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from the Contractor's License Law for th lowing reason,
(Sec.7031.6,Business and Professions Code: Any city or county which re ul a 9g��ppermit to
construct,alter,Improve,demolish,or repair any structure,prior to its issuance, I'S the BUILT-UP ROOF Ll t❑
applicant for such permit to file a signed statement that he a Ibe ed pursuant a prdvleiona a
of the Contractor's License Law(Chapter a(commencing with Se on 7000)of D Ion 33 of the i;I
Business and Professions Code)Qr that he Is exempt therefrom dMb basis a alleged ASPHALT SHINGLES JI rll, ❑
exemption.Any violation of Section YQ31.5 by any applicant for a p It su one a Ont to
a civil penalty of not more than five hlh1ye l dollars IS ).):
❑I,asownercfthe property,orrays Ioyees wage as r cation,will do WOOD SHAKES C11y �19g6
the work,and the structure Is not Intontled rd'N'-r sal 4 Iness and Poll (/ 9
alone Code: The Contractors License Law a not 1 n or ofpropertywho builds or N L
Improve.thereon,and who does such wg fpii 'elf arpp Ills awn emleeprovided that WOOD SHINGLE
$
such Improvements are not intended on Nerell „II,- ever,the building or Improvement f yykU
Is Bold within one year of completion '
own Ill have the burden of proving that he did OTHER(SPECIFY) El
build or Improve for purpose of sale.).
❑I,as ownerof the property,am exclalvelyyon>rating with licensed contractors to construct
the project(Sec.7044,Business and Profession 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 contractor(s)licensed pursuant to the Contractors License Law, PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B 8 P.C.for this reason
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 of Consent to sell-Insure for Worker's Compensation, /x� n wn Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this t(/ /f
permit Issued. ✓C"f {rJ r/Un1 II.IWI I
nave and will maintain Workers Compensation Insurance,as required by Section 3700 of J Seismic
the Labor Cotle,for the pedormanca at the work for which this permit Is Issued.My Workers
Compo` tjion�Ina rants carrior and Policy number are: Total
Carrier
VlLl Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' ON
COMPENSATION INSURANCE N.C.❑
(This section need not be completed if the permit le for one hundred dollars($100)or lees.)
I certify that In the performance of the work for which this permit Is issued,I shell not employ
any parson in any manner sons to become subje o me workare'cam enation Laws of call. All roofs shall be inspected prior t any roo i g ma "Jing
fornia./ � installed. If a roof is installed without first obtaining an
Date (P"" p Appllpant inspection,I agree to remove all new materials for inspection.
subject toEhe WorkersTO 'Compensation Prr mak
ome
v to ofehefic o0Cotle,y Illn.muetalshould comply Applicant understands and will comply with all non point
with such provisions or this permit shall b dee ad revok d. source regulations.
I certify that I have read this applicetlo 1 tete that the above Information le correct.I spree
to comply with all city and county ordinances and slate laws relating to building construction,and All roof coverings to be class°C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino epalnat liabilities,
judgments,coats and expenses which may In any way accrue against said City consequence
of the granting of this permit. $ ATUR 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY