R 4916a
i
APPLICATION FOR
REROOF PERMIT
- BUILDING ADDRESS
. IO f q/ /OSN in C, Pi.
OWNER'S
NAME Cr
) I el L��osn%Io
ADDRESS S R hl Q. RS 4? L D ye,
CITY OF CUPERTINO
INSPECTION DIVISION
(408)777-3228
NAME 11 C is -Uu ✓q
ADDRESS CIITYY8z1P yG % C 9r�i �O k QJ ✓qq�
PHONE —.
o1K - C" -f ys3�
LICENSE S-0;> r -V?
NUMBER
hereby affirm that I am licensed under provisions of Chapter B (commencing with Section
700 0) of Division 3 of the Business and Professions Code, and my license Is In full force and
effect. 61, /"-y 9 .V
License Claes `- 3" LIc. Number
Data �O 9 ConiraMor
OWNER•BUILDERDECLA ATIC
I hereby althat I am exempt from the Contractor's License Law for the following reason,
(Sac. 7031.5, Business and Professions Code: Any city or county which requires a permit to
construct, alter, 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
of the Contractor's License Law (Chapter S (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
exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
s civil penalty of not more than live hundred dollars ($500).):
f-I1.a. owner of the orooert, or my emolove.. with wane. a. their sole will nn
who
Improves msmOn, enO who OOes eucn work merest? Or enough me Own employees,rovcled In"
such Improvements are not Intended or offered for sale. If, however, the bulltling or Pmprovement
Is Bold within one year of completion, the owner -builder will have the burden of proving that he did
not build or Improve for purpose of eels.).
01, as owner of the property, em exclusively contractin with licensed contractors to construct
the project (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) licensed pursuant to the Contractor's License Low.
❑ 1 am exempt under Sec. ,B A P. C. for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
01 have and will maintain a Certificate of Consent to self -Insure for Workers Compensation,
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
pele Iseu
rmetl.
ell have entl will maintain Worker's Compensation Insurance, as required by Section 3700 of
the Labor Code, for the performance of the work for which this permit Is Issued. My Worker's
Compsnsallon In{eyran{�§ carrler and P;70 number ere:
Carrier �" 4' ` �yA'r Policy No. /��el?e
4/0
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.p
(This section need not be completed if the permit Is for one hundred dollars ($100) or less.)
I certify that In the performance of the work for which this permit Is Issued, I shell not emootoy
any person In any manner so as to become subject to the Workers' Compensation Laws of Call.
or
his.
Cate Applicant
NOTICE TO APPLICANT: II, after making this Certificate of Exemption, you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
with such provisions or this permit shall be doomed revoked.
I certify that I have read this application and state that the above information Is correct. ) agree
to comply with all city and county, ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the above-mentloned property for In.
spection purposes.
(We) agree to save, Indemnify and keep harmless the City of Cupertino against liabilities,
Judmemo, costs and expenses which may In any way accrue against said City In coneaquence
of the granting of this permit.
PRE -INSPECTION: I PLYWOOD:
OFF INSPECTION:
INSP.
PERM
NUMBER R- 4916
PERMIT
RESIDENTIAL COMMERCIAL OTHER
YES ❑ If yes - I understand that a Class A
roof assembly is required.
NO ❑ Initial I.C.B.O. N
NUMBER OF EXISTING COVERINGS
TO BE REMOVED TO BE RETAINED
TYPE OF ROOF COVERING
EXISTING
BUILT-UP ROOF
❑
ASPHALT SHINGLES
❑
WOOD SHAKES
WOOD SHINGLES
❑
OTHER (SPECIFY) ❑
ROOF
SHINGLES
11
S
VSPECIFY)
c�A�KPES V[�'�rg rC"LES �, ❑�<�J
PROVIDE I.C.B.O. REPORT NO��
PROVIDE MFGR. INSTALLATION SPECS.
APPLICATION DATE1 VALUATION PERMIT FEE
�✓/� %� $SOD, Q 0 Building�
Seismic •P'G
Total
PERMITAUTH pp TION DATE
V� b
All roofs shall be inspected prior to any roofing, materia being
installed. If a roof is installed without first obtaining an
inspection, I agree to remove all new materials for inspection.
Applicant understands and will comply with all non point
source regulations.
All roof coverings to be class "C" or better.
SIGNATUR F APPLICANT UATE
IN -PROGRESS:
DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION I
OFFICE COPY