R 4744•
•
OFFICE COPV
PERMIT R_ 4744
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
O
RESIDENTIAL-)—SCOMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
' N / y I_ ■ ` , I
VES ❑ It yes — I understand that a Class A
NAME ` ' /rte 1( 1 , 1
,
- roof assembly is required.
NO _ Initial I.C.B.O. q
,gq� �j /
o
EXISTING ROOF COVERING
ADDRESS { LA'YLI 5117
5 R iltlllrrr [ 9/-7715
PHONE /S" _ '- 9 36
//T
NUMBER OF EXISTING COVERINGS
"
BE REMOVED TO BE RETAINED
CONTRACJjj)a8$ /� }/
am% V } 1 �2 /'�)Z66TO
NAME 'J1 tI�'vJ N J 15"
ADDRESS SR # SL
TYPE OF ROOF COVERING
CITU &ZIP .0 _ L7� I r 1
EXISTING
5441 650 e -A 175-//
PHONE !6eD for — 226 L/ 2 b -
BUILT-UP ROOF O'f
LICENSE
NUMBER
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
WOOD SHAKES S
7000) of Division 3 of the Business and Professions Code, and my license Is In full force and
<�
effect
U,,n
License Clese� Llc.
WOOD SHINGLES ❑
Number
Z _I _,Ft,
OTHER (SPECIFY) ❑
Date cont....
OWNER-BUILDE 'ON
I hereby alllrm that I am exempt from the Co ctor' is nee Law for the following reason.
PROPOSED
(Sec. 7031.5, Business and Professions Code: ny ci or ounty which requires a permit to
construct, alter, Improve, demolish, or repair any structur , 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 Lew (Chapter 9 (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 then five hundred dollars ($500).1:
E] 1, as owner of the property, or my employees with wages as their sole compensation, will do
WOOD SHAKES ❑
the work, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Proles.
sions Code: The Contractor's License Lew does not apply to an owner of property who build$ or
Improves thereon, and who does such work himself or through his own employees. provided that
WOOD SHINGLES ❑ -
such Improvements are not Intended or offered for eels. If. however, the building or Improvement
Is sold year of
OTHER (SPECIFY) /'S��
forpurposetofStheownerbullhrwillhaustheburdenofpmvingthathedid
net bulltl or Improve for purpose io sale.).
or
��
❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct
40 9'ar
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 bulltl$ or Improves thereon, and who contracts for such projects
with a contractors) licensed pursuant to the Contractor's License Law,
❑ hem exempt under See. ,B & P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owns r Date
WORKER'S COMPENSATION DECLARATION
APPLTTlO DATE
VALUATION
PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑ 1 have and will maintain a Certificate of Consent to self -Insure for Worker's Compensation,
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
�',(�
G
Bulldln S
g
p rm�it is Issued. /�
Y7rl heve antl will maintain Worker'. Compensation Insurance, as required by Section 3700 of y��
thNRbor Cotle, for the performance of the work for which this permit Is Issued. My Workers
Compensation euranc rrlot and Policy number are:
y 1986
�}/- L
4f'Ei/
$BISRIIC
Total
AI
PERMIT'AUTHORIZATION
DATE
Carrier Policy No. 9Y-i27D77
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.p
(This section need not be completed If the permit Is for one hundred dollars (51 00) or lass.)
I certify that In the performance of the work for which this permit Is Issued, I Shall not employ
All roofs shall be inspected prior to any roofing material being
any person In any manner so as to become subject to the Workera' Compensation Laws of Cali.
fornia.
installed. If a roof is installed without first obtaining an
Data Applicant
inspection, I agree to remove all new materials for inspection.
NOT subject to Eh APPLICANT:
o k ras'Compense ion provisions of tthelcate of Labor Code, Exemption.
olu mustforthwith lbecome
comply
Applicant understands and will comply with all non point
with such provisions or this permit shall be 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
All roof coverings to be class "C" or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
epiW purposes,
(WeI agree to save, Indemnity and keep harmleae the City of Cupertino against liabilities,
judgments, coats and expenses which may In any way accrue against said City In consequence
gf the granting of this permit.
Si 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPV