R 4533 APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 4533
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN DAYS PERMIT ISSUANCE O
WI MVSS FROM LAST CALLED INSPECTION.,
BUILDING ADDRESS
o�a353 I�•v' �� �� ���v RESIDENTIAL COMMERCIAL OTHER
OWNERS Ik-•�� I/�1� /�� 11/� HAZARDOUS FIRE AREA
NAME l J I'I �1 I lJl ,<M I YES ❑ If yes s I assembly
is req that a Class A
roof assembly is required.
NO Initial LC.B.O.p
ADDRESS a � `�'e-rs� • �.-1�,JZ� EXISTING ROOF COVERING
PHONE — IQ �-� NUMBER OF EXISTING COVERINGS -42-
CONTRACTOR'S.
NAMEYMaALq_ 1 �c TO BE REMOVED TO BE RETAINED
ADDRESS �r TYPE OF ROOF COVERING
CITY&ZIP
EXISTING
PHONE BUILT-UP ROOFLICENSE
❑
NUMBER ASPHALT SHINGLES El
LICENSED CONTRACTORS DECLARATION
hereby affirm that em licensed under lessons of Chapter a(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,entl my license Is In full force end
effect.
?J 3 WOOD SHINGLES ❑
License Class I Lic.NumbeADrcou
/
a7".;a/"`�'(p OTHER(SPECIFY) ❑
Date Contractor
OWNER-BUILDERContractors
PROPOSED
I hereby affirm that am exempt from the e: Any
w for re followingitresreason. /
(Sec.7031.5,Business and Professions Code: Aw I.,roqulres a permit a (o
construct,alter,Improve,demolish,or repair any structure,prior to its issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
• of theContractor's License Low(Chapter a(commencing with Section 7000)of Division 3 of the
Buslnass and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES Elexemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of not more than five hundred dollars($500).):
❑l,as owner of the property,or my employees with wages as their Bole compensation,will do WOOD SHAKES
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profes.
slots Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who dose such work himself or through his own employees,provided that ❑ ,
such Improvements are not Intended or offered for sale.II,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) 13not build or Improve for purpose of Sale.).
❑I, sowneroftheproperty,amexclusivelycontractingwithlicensedcontractorstoconstruct PROVIDE LC.B.O.REPORT NO.
theproject Sec.7044,Business and Professions Code:The Contractors License Law does not
apply to an owner of property who builds or improves thereon,and who contracts for such projects
with a contractor(s)Iicensetl pursuant o the Contractors License Law, PROVIDE MFGR.INSTALLATION SPECS.
E]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 afllrm under penalty of perjury one of the following declaration: A Q
[:]I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, P W BUlldm
as provided for by Section 3700 of the Labor Code,for the performance of the work or which this if (U�,.�x,
permit Is issued. FEB1 1996 � w $els I
La have and will maintain Worker's Compensation Insurance,as required by Section 3700 0l IBB 161 1.7.701
- di
Lha Labor Code,for the performance of the work or which this permit Is Issued,My Worker's
Compensation Ii c carrierentl PolicynymCerare: � �I f Total
Till L,r'LGY,'� V I V' '
Carder t\ FROM Na P RMITAUTHORIZATION DATE
CERTIFICATE EN EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N,C.p
(This section need not be completed If the permit Is for one hundred dollars S1 00)or loss)
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 Call. All rootn shall be-inspected prior to any roofing material being
lornla. installed. If a root is installed without first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
become
subject o the Workers'T C5 TO C Compensation n provisionls of the 11Labor Code,cate of you must forthwith comply Applicant underst and will comply with all non point
with such provisions or this permit shaki deemed revoked. SOUfCe regUlatl S.
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 ass"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property or In-
spection purposes.
(We)agree to Save,Indemnify and keep harmless the City of Cupertino against Ilabllltles,
judgments,costs and expenses which may in any way accrue against said City In consequence
of the granting of this permit. 4JWtMURVOF APPLICANT DAT
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
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