R 4981 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 4981
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK a NOT STARTED
'
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
WI180 DANS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
Q' /��,. 1,
I(b —1 '+ " &ZjssL06 rL aye s- RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS
p A,r HAZARDOUS FIRE AREA
NAME M W. gc r�►i s_ AL)A�� NES If yes—I understand that. Glass A
qof assembly(sand that
NO Initial I.C.B.O.`ff
ADDRESS 10432 sala wegr Ave- EXISTING ROOF
{{COVERING
PHONE ?f 3 — 6+
NU BER OF EXISTING COVERINGS 1 LAYC<
CONTRACTOR'S
2ENAIS5A�c.E �FUJCA Cb,i,, WG• T08EREMOVED SQ TO BE RETAINED
NAME
ADDRESS -7 a
TYPE OF ROOF COVERING
CITY&ZIP 2L Y2 Ut0C_0L/0 AUC—.i S.1.;CA.
EXISTING
PHONE e¢mg) 4
4% '- (Z617- BUILT-UP ROOF ❑
CENSE
NUMBER 515.9�36 ASPHALT SHINGLES ❑ 1
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter g(commencing with Section WOOD SHAKES '� L ' ,
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and //
effect. q q WOOD SHINGLES ❑ C�
LicensAe Class—� � t Llc.Number �� 1
DsteAw'' IT Contreclor RA"AU,16 Ce ROOM* OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License law for the following reason.
(Sec.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 BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is licensed Pursuant to the provisions
of the Contractor's License Law(Chapter 0(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
a civil penalty of not more than live hundred dollars($500).):
❑l,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Proles.
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES
Improves 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 building or Improvement
Is sold within one year of completion,the owner-bui lder will have the burden of proving that he did OTHER(SPECIFY) qT(
not build or Improve for purpose of sale.). ¢y
1,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO. C.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contrectons)licensed pursuant to the Contractor's License Law, PROVIDE MFGR.INSTALLATION SPECS.
01 am exempt under Sec. ,B&P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: I
❑1 have and will maintain a Certificate of Consent to sed-Insure for Workers Compensation, v
as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which this AUG � Building
permit is Issued. AUVI 19 19 6 $eIBmID 42c1
1d I have and will maintain Workers Componsallon Insurance,as required by Section 3700 of
the I- bor Code,for the performance of the work for which this permit Is Issued.My Worker's '
)y
Compensation Insurance carrier and Policy number are: lir Vt VVI'L tl IkU1 Total
r CarrierST'15M rVNh Policy No. ZS5'96 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
s COMPENSATION INSURANCE IN CQ
(This section need not be completed if the permit is for one hundred dollars($100)or less.)
1 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 subje tion to the Workers'CompensaLewe of Ce11- All roof.^.s all beinspected prior to any g
roofing material bel
fornia. - installed. If a roof is installed without first obtainingan
Date AU(- Applicant �' inspection,I agree to remove all new materials for inspection.
subject lI.Ethe Worrke s'Compensation fafter
provisionathis
ofCertificate
the Labor Code,you mustuforthwith becomecomply Applicant understands and will comply with all non point
with such provisions or this permit al be deemed revoked. SOU r e 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 retaking to building conalruction,and All occV rin t0 b0 rllaSS"C"Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property br, Qp
ep IW I purposes. AU�p, 49 7 16
(Wel agree to save,penesIndemnifyw and keep I harmless the City of Cupertino y In con Ilebllen e,
of the gran coats and expenses which may In any way accrue against said City In consequence
of me granting of permit. S GNATURE 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
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