R 4862 PERMIT R_ 4862
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
21.S41,5` /ZK4ord�> 0R- RESIDENTIAL COMMERCIAL OTHER
OWNER'SfN ❑ HAZAR OUS FIRE AREA
S )
NAME �j y YES if es—I understand that a Class A
1 S y �R, ' � �,I S "Ooof assembly is required.
11 NO ❑ Initial I.C.B.O.N
ADDR�E�SS, Sa M Lr! A)Sp Abc1tl S EXISTING ROOF COVERING
PHONE i' �''/ / NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME12r.A 5- .Val LLA-iI TO BE REMOVED TO BE RETAINED
ADDRESSy 1 TYPE OF ROOF COVERING
CITY A 71P--� CiS 1 J EXISTING
PHONE BUILT-UP ROOF ❑
CENSE
NUMBER rZ6 ASPHALT SHINGLES El
LICENSED CONTRACTORS DECLARATION
hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES
700 0)of Division 3 of the Business and Professions Code,and my license Is In lull force and
effect. WOOD SHINGLES ❑
License Cfass _ Llc,Number -2—(,Jp -7-1
Date 5- 2- k Con for b• OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Lawlor the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county Ich requires a permit to
construct,alter,Improve,demolish,or repair any structure,prior to l enc9g,�also requires the BUILT-UP ROOF ❑
appllcanl for such permit to Ills a elBnetl statement that he Is Ilcena p u¢nf'to the provlalane
of the Contractors License Law(Chapter B(commencing with Sqq o )of Ivlsion 3 of the
• Business and Professions Code)or that he is exempt therelrpM end a for the alleged ASPHALT SHINGLES ❑
exemption.Any violation of Section 7031.5 by any applicant ape a the applicant to
e civil penalty of not more than live hundred tlollara($50�)
❑I,as owner of the property,or my employees wll i g as "a a compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offeretl'I a e 044,Business and Profits.
alone Code:The Contractor's License Law tlo 'owner of property who builds or WOOD SHINGLES
Improves thereon,and who doessuchwork e 1 opgh his own employees,Improvement provided that ❑
such Improvements are not or owne el .ill however,the en of pr or Improvement
Is soldwithinor
prove arofcompletion,the owner- rwlll have the burden of proving that he did OTHER(SPECIFY)
net 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 not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or improves thereon,and who contracts for each projects
with a contractor(a)licensed pursuant o the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B 8 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:
❑I have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, Building,J
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this �(�
permit is Issued. �j✓;m IC
❑ have and will maintain Workers f the work
for Insurance,as permit Is Is by Section Worker's of
the Labor Cotle,for me performance of the work for which Ihl9 permit la laeuetl.My Worker's �Q �
Compensation l' Lir°�ce carrier entl Policy number are: CII I Vr "r Lit Total /�Q
Carrier-- c Q� �r*p Policy No. (3 73a o;? PERMIT AUTHORITION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION
Perm 0 or a N.O(]
(This section need not be completed If the permII le for one hundr ollare($100)ar less.) IV`����LR•- C///a/C� v TZJ`
I certify that in the performance of the work for which in er le shell not employ
any person in any manner so as to become subject to th ars' pensallon Laws elcall- All roofs shall be inspected prior to any roofing material being
ferala7.}�/ installed. If a roof is installed without first obtaining an
Datevr�—quy Applicant inspection,I agree to remove all new materials for inspection.
subject
TICErTw APPLICANT: If,
aft tion akinslo o the"If
r Co"Imption,you should become Applicant un rstands and will comply with all non point
you must forthwith comply p Y
with such provisions or this permit shall be deems rev d, source re do
I certify that l have read this application and state t of 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 o e ' gs D class"C" better.
hereby authorize representatives of this city to enter upon the above-mentioned properly for In.
spection purposes.
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities,
judgments,costa and expenses which may In any way accrue against said City In consequence
• of the granting of this permit. SI UR F 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