R 4995C-1
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OFFICE COPY
PERMIT R- 4995
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
,Z/4 4 g7<.�cAa� �c.
✓
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
'/
144l 4141&61w1
YES ElIf yes — I understand that a Class A
NAME
NO roof assembly is required.
E] Initial I.C.B.O. k
EXISTING ROOF COVERING
9 �Gt.6!%.
ADDRESS 14/4`1
NUMBER OF EXISTING COVERINGS /
_ gq Z.r--
PHONE
CONTRACTOoR'S-,
� e
NAME /��- GST3 ISG/�fi
TO BE REMOVED TO BE RETAINED
ADDRESS /O & ��3a
TYPE OF ROOF COVERING
7L„
CITU &ZIP /L %T
F_X TING
�iff%SZi y4ri
PHONE
B
BUILT-UP ROOF ❑
LICENSE CJ� 7� j
NUMBER 7/,
ASPHALT SHINGLES ❑
WOOD SHAKES �tJ
LICENSEDdunderCONTRACTORSsof Chapter 9 (N
I hereby that I emusi nes under provisions of Chapter a (commencing calif Section
iaffirmslon
7000) of Division 3 0l the Business and Professions Code, and my license Is In lull torte and
\
effect' 1 L 17
WOOD SHINGLES ❑
License Class Lic. Number T
OTHER (SPECIFY) ❑
/
10 - 9L Q2/1'L GiT °r'L �beL/ ✓
Dote - --' Contractor
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Lew for the following reason.
PROPOSED
(Sec. 7031.5. Business and Professions Code: Any city or county which requires a permit to
construct, after. Improve, demolish, or repair any structure, prior to Its Issuance, also requires the
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
BUILT-UP ROOF ❑
of the Contractor's License Law (Chapter a (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he la exempt therefrom and the heels for the alleged
ASPHALT SHINGLES ❑
exemption, Any vlolatlon of Section 7031.5 by any appllcant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars ($500).):
❑I, as owner of the property, or my employees with wages as their sole compensation, will do
WOOD SHAKES
the work, and the structure le not Intended or offered for sale (Sec. 7044, Business and Profee.
-
alone Code: The Contractor's License Lew 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 Improvements are not Imanded or offered for sale. It, 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) ❑
not build or Improve for purpose of sale.).
1,
[2 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 not
(k u
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 Lew.
'
El I am exempt under Sec. ,B & P. C. for this reason
PROVIDE MFGR.INSTALLA� $� ��qs
t.
Owner Dale
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATIONr V
)rctPERMIT FEE
1 hereby affirm under penalty of perjury one of the following declaration:
❑ I have and will maintain a Certificate of Consent to self -insure for Workers Compensation,
for by Section 3700 of the Labor Cod°, for the the for
Building
g
performance of work whim this
pe mit is Is
permit isIssued.
vd_Y�
24e � w
�I have and will the rmancWorker's Compensation the workfor Ineurence, as repulsed by Section 3700
t Labor Code, for the of the work for which this Is leauetl. My Workers
r.
Seismic �6G
_ pert
performance permit s
Compensation Ineurence carrier antl Poyycy number are:
�r�� —yL
Total
PERMIT AUTHORIZATION
DATE
Carrier �vf�9
PROMNo.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.
(Thio section need not be completed 11 the to for one hundred dollars leas.)
permit ($100) or
e
I certify that in the performance of the work for which this permit Is Issued, 1 shell not employ
All roofs shall be inspected priory roofi g material being
any person In any manner so as to become subject to the Workers' Compene errtewe of cell-
for"le' % /
—/° — g
installed. If a roof is installs ithout first obtaining an
inspection,
[lata / Applicant
I agree to remove all new materials for inspection.
subjects toTO theWorrkerss'Compensatio provlmakinelons of the Labocate r Code, yOlu Mustufo forthwbecome
ith comply
Applicant understands and will comply with all non point
with such provlalons or this permit shalgbe deemed revoked
Source regulations.
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
of! to be class" efter.
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 against liabilities,
Ser
71Q _gIl
judgments, coats and expenses which may In any way accrue against sold City In consequence
oft 9 granting of this permit.
SIGN 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY