R 4829EJ
OFFICE COPY
PERMIT R- 4829
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
Lco
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA '
Class
YES (] r000f
NAME V
assembyaarequired,hat
NO Initial I.C.B.O..Iff
s
ADDRESS
EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS
TO
PHONE
CONTRACTOR'S
NAME 4 I�,..�T t W
BE REMOVED TO BE RETAINED
ADDRESS
TYPE OF ROOF COVERING
CITY & ZIP
EXISTING
PHONE
BUILT-UP ROOF ❑
CENSE
NUMBER
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
hereby affirm that I am licensed under provisions of Chapter 8 (commencing with Section
WOOD SHAKES
7000)of Division 3 of the Business and Professions Code, end my license Is in full force and
(� t F5�
WOOD SHINGLES El
License Class LIC. Number •
(SPECIFY) ❑
PROPOSED
%— 3 /—ria fid' 6�j%t 141111OTHER
Data Contractor
OWNER BUILDER DECLARATION
I hereby affirm that am exempt from the License Lew for the ng
e: Any t,
(Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to
requires permit
h, or repair prior lo Its Issuance alsoires
constapplicant
BUILT-UP ROOF ❑
signedstateny menthatstructure,
nsed
applicant lar such permit to Ills a signedstatement9 (comm that he Is licensed pursuant to the provisions
ofthe License Lew (Chapter a (commencing with 7000) of the
the 3 0l the
^
Y�
ss and Prof
and Professions Code) or that he Is exempt therefrom and for
ens the heels for the alleged
exemption. violation Section 7031.5by
exemption. Anyf lora
ASPHALT SHINGLES
of antforam
any applleent permit subjects the applicant to
not
a civil penalty at not more than flue hundred dollars ($501
E] 1, as owner of the property, or my employees with wages as their sole compensation, will do
WOOD SHAKES ❑
the work, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Profen-
slons Code: The Contractors License Law does not apply to an owner of property who builds or
Improves thereon, and who does such work himself or through his own employees, provided that
WOOD SHINGLES ❑
such Impmvaments are not Intended or offered for sale. If, however, the building or Improvement
Is sole within one year of completion, the owner -builder will have the burden of proving that he did
OTHER (SPECIFY) ❑
not build or Improve for 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 Contractors License Law does not
PROVIDE I.C.B.O. REPORT NO.
apply to an owner of property who builds or Improves (harbor, and who contracts for such projects
with a corsractons) licensed pursuant to the Contractor's License Law.
] 1 am exempt under Sec. ,S & P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner
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,
as provided for by Section 3700 a1 the Labor Code, for the performance of the work for which thle
lave
Anu�
�/YY�,//�� '/p
Build n
permit
and
❑ I have end will maintain Worker's Compensation Insurance, as required by Section 3700 0l
Labor Code, for the the for
/J
C/f T
/)
SeI5f1 'C s
,the performance of work which this permit is Issued. My Workers
Compensation Insurance carrier and Policy number
V •
1 UUt•
Total
are:
LI111b
i
Carrier 0 4:70 A/0 Policy Noll ���+r'Xe�
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.I]
(This section need not be completed If the permit Is for one hundred dollars ($100) or lose.)
1 cerilfy that In the performance of the work for which this permit Is Issued, I shall not emptoy
any In any become
All roofs shall be inspected prior to any roofing all b in
person manner so as to subject to the Workers' Compensation Lowe of Cali.
farnla.
installed. If a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
subject to theICE OWorkeres' Compel, after nsation rrovielonls of thecate of Labor Code,oust should become
pp you must forthwith comply
with such provisions isle permit scation deemed
Applicant understands and will comply with all non point
p y p
SOU(Ce regulations.
r thatrevoked.
certify that have read this applicationand state thattheabove Information is correct, agree
tocomplywith all city and county ordinances and state laws relating tobulltlingconstruction,
All roof C r gS t0 b0 class "C"Or better.
y fand
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
In-
spection purposes.
(We) agree save, indemnity and keep harmless the City of Cupertino against Ilebilitlea,
'{
e±_1!! "— y�
s
coats and expenses which may In any way accrue against said Olt, in consequence
ec.AT-- ,�—
SIGNATURE URE OF APPLICANT"DATE
of the gran
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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION -
OFFICE COPY