R 4905 APPLICATION FOR CITY OF CUPERTINO NUMBER R- 4905
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 ^y�
Z .-1 '3 4AC_ C �i RESIDENTIAL COMMERCIAL OTHER-
OWNER'S
THER
OWNER'S� HAZARDOUS FIRE AREA
NAME1_'/,f�1 1 S �"- DMP-0W Vleaf�S YES ❑ —f assembly streqund ired. ClassA
NO ❑ Initial I.C.B.O.If
ADDRESS EXISTING ROOF COVERING
PHONE �Z) Z9'f' I O3 NUMBER OF EXISTING COVERINGS
CONTRA�R' �.�
NAME IAV /n(� I\ TO BE REMOVED TO BE RETAINED
—� oe , t1�
ADDRESS C CC,, T TYPE OF ROOF COVERING EXISTING
-
CITY8ZIP1//��'''/.t] 3p So. � � JL.• S4✓� `lo$C �S�� L
PHONE ` `�V� s0n BUILT-UP ROOF
LICENSE S Z O ASPHALT SHINGLES
NUMBER ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES. ❑
7000)of Division 3 of the Business and Pro(esslons Code,and my license Is in full force and
allow. /' WOOD SHINGLES E]License Class `--� LIc.Number
DRIB
Z OTHER(SPECIFY) 11Cont
OWNER-BUILDER DECPROPOSED r
I hereby affirm that em exempt from the Contractor' LIc a Lew for the following reason.
(Sec.7031.5,Business and Professions Code: Any cit county which requires a permit to
construct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF MAY
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions +(I, !J"�
of the Contractor's License Lew(Chapter 9(commencing with S Ion 70001 of Division 3 of the 1996
• Business and Professions Code)or that he Is exempt Iharsfr3 d the beats for the alleged ASPHALT SHINGLES ❑
exemption.Any violation of Seaton 7031.5 by any applkl(nt for a pe pubjecte the applicant to
e civil penalty of not more than live hundred tlo st9(6500 VII.f lJf 1xu(-Lfi I IIVV
❑I,as owner of the property,or myempI see with wee compensation,will do WOOD SHAKES ❑
the work,entl ins structure le not Inlentl rbHeretl or 44,Business and Profits-
The Cod The Contraclora License 1¢ ttpp en owner of property who builds or WOOD SHINGLES
Improves thereon,and who does each wor qt. rough his own employees,provided that ❑ M
such Improv withiemen�are onot incompletion,
rentletl or the owner-bus If,ilder however,thebuilding or Improvement he did
OTHER (SPECIFY)
ret build Mone yearofpure let of sale.).Owner-builderwill have the burden at proving that he tlid
not bulitl or Improve for purpose of cele.).
❑I,as owner of the property,em 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 projects
with a contrectods)licensed pursuant to the Contractor's License Lew, PROVIDE MFGR.INSTALLATION SPECS.
❑I em exempt under Sec. ,B 6 P.C.for this reason
Owner Dare
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the(allowing declaration:
❑1 have and will maintain a Certificate of Consent to self-insure for Workers Compensation, ,
as provided for by Section 3700 of the Labor Coda,for the performance of the work for which tole / Building 1' /r�//
i
00
permit Is Issued. 9 L a 00 ,
th.oNIAl have entl will maintain Workers Compensation Insurance,as required by Section 3700 of Z.4 Seismic
bor Code,for the performance of the work for which this permit Is Issued.My Worker's
number are:
compensao =ca[ rtnd Total ^
^Carrier
Y
Policy No &7- R.tj PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed II the permit is for one hundred dollars($700)100)or lase.)
I certify that in the performance of the work kr Wk-perrW,is ,I shell not employ
any person any men er so es to bac Oct the work m Onto L e of all- All roofs shall be inspected prior to any roofing material being
forma. installed. If a roof is installed without first obtaining an
F1
Date
Applicant inspection,I agree to remove all new materials for inspection.
NOTt TOA LICANT: II,alter making th a GkgIW of Exemption,you shoultl become Applicant understands and will comply with all non point
subject to the War ere'Compensation provision.of the bar Cotle,you must forthwith comply pP p y p
with such provisions or this permit shallibe dee o r kao, S
I certify that I have read this appllcalion and state that the above Information la correct.(agree /
to comply with all city and county ordinances and state laws relating to building conelrucllon,antl All rO f- OVerl S be as
"C/or better.
hereby authorize representatives of this city to enter upon the above-mentionetl property to
spection purposes.
(We)agree to save,indemnity and keep harmless the City of Cupertino against Ileblllt 2
judgments.costs and expenses which may In any way accrue against mid Cly In consequence
• of the granting of this permit. NAT OF APPLICANT DE
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