R 46860
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W
OFFICE COPY
PERMIT R_ 4686
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
7 i5F/ / /�Cl�v J
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
/�
�Q��K/�
YES ❑ ItClassA
NA ME ( Q�/C�G-`�
roof as is required.
NO Initial - LC.8.0. #
_
37 57e eG�✓S
EXISTING ROOF COVERING
ADDRESS—422 A#A
nn
512
NUMBER OF EXISTING COVERINGS
PHONE f� .S� v
TO BE REMOVED TO BE RETAINED
CONTRACTOR'S
NAME �" �/ /�l/G /�
ADDRESS S7/ �G
1 'A�9iA/ p sr s/�
TYPE OF ROOF COVERING
CI-- / C /,tiI/7
TU&ZIP-
.
EXISTING
a
PHONE /`
BUILT-UP ROOF ❑
LICENSE�i'
NUMBER /
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter g (commencing with Section
WOOD SHAKES ❑
7000) of Division 3 of the Business and Professions Code, and my license Is In full force and
effect.
A
License Class Lie. Number 'f �// � 7
WOOD SHINGLES ❑
Date / contractors��7y�Cn?
OTHER (SPECIFY) ❑
OWNER -RI u nER DECLARATION /
I hereby affirm that I am exempt from the Contractors License Law for the following reason.
PROPOSED
(See. 7031,5. Business and Professions Code: Any city or county which requires a permit to
construct.alter.Improve,demolish, or repair anystmclure, prior to its Issuance, also require. the
BUILT-UP ROOF
applicant for such permit to file a signed statement that he Is licensed pursuant to the previsions
of the Contractors License Law (Chapter g (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he Is exempt therefrom and the basis for the alleged
ASPHALT SHINGLES
exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e 00 penalty of not more than five hundred dollars ($500).):
WOOD SHAKES
❑I, as owner of the property, or my employees with wages as their sole compensation, will do
the work, and the Structure Is not Intended or offered for Bala (Sec. 7044, Business and Profen
Ge
dons Code: The Contractor's License Law does not apply to an owner of property who builds or
Improves
WOOD SHINGLES ❑ /�
thereon, and who does such work himself or through his own employees, provided that
such Improvements are not Intended or offered for sale. If, however, the bul ding or Improvement
Is sold 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 Contractor's License Law does net
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 contrectorls) licensed pursuant to the Contractor's License Law,
PROVIDE MFGR. INSTALLATION SPECS.
❑ 1 am exempt under Sec. ,B $ 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:
❑ have and will maintain a of he Lab of Consent to eperforure force Workof the rs woComp which
for by Section 3700 of the Labor Code, for the performance of ins work for which lhla
this
permit
Buildin
permit Is Issued.
p Is Is
r O
/y
Workers Insurance, as required Section
❑ have ane w111 maithe
Seismic - rA_A
P
pert f the work for
the Labor Code, for the performance of me work for which this permit Is Issued. My Worker's
su Worker's 's
Compensation
i 6
Insurance sassier and Polley numbs are: (
VU �\�N�
Total
Carrier Policy No.
!..
VPC MIT AUTHORIZATION
DAT
CERTIFICATE OF EXEMPTION FROM WORKERS.
COMPENSATION INSURANCE N.C.0
(This section need not be completed If the permit Is far one hundred dollars ($100) or lees.)
I certify that In the performance of the work for which this permit Is Issued, shall not employ
any person In any manner so as to become subject to the workers compo Bauon Laws of cell.
All roofs shall be inspected prior IU any roofing material being
fornla.
Date 4 Applicant /
installed. If a roof is installed without first obtaining an
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It, after making AS Certifice a of Exemption, you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
Applicant understands and will cora
PP ply with all non point
with such provisions or this permit shell be deemed revoked.
source regulations.
1 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 elate 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-mentloned property for In-
ep purposes.
(We)
(We) agree to cave, and keep hay ay the Clry of Cupertino against liabilities,
expenses
Gmanb, costa and expenaea which may in any way accrue against said Cly In consequence
SIGN TURFA�CANT
oltRegrantingofthispermit.
of
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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY