R 4731 (2) PERMIT
R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 47 31
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
BUILDING ADDRESS
180 DAYS FROM LAST CALLED INSPECTION.
/
GL6� ' 4, 4 - RESIDENi COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
NAME eaL4A:,- I'
VES ❑ If yes—I Understand that a Class
{�K I tool assembly is required.
r NO ❑. Initial I.C.B.O.N
ADDRESS9�'�GL 157; EXISTING ROOF COVERING
PHONE ` �' NUMBER OF EXISTING COVERINGS /w✓L
CONTRACTOR'S
NAME �(.f�,'� TO BE REMOVED � TO BE RETAINED
( ! yL
ADDRESS ' / / TYPE OF ROOF CIDr
CITY 8 ZIP EXISTING
PHONE u7�� �.3 — lS`�,� BUILT-UP ROOFLICENSE
❑C�
NUMBER / `.. - ASPHALT SHINGLES ❑ t/j_ '-
LICENSED CONTRACTORS DECLARATION rn/
I hereby allirm that I em licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES CG
7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and
effect.
9� �l� ❑
Llcenee Claes Sz- —�C— Lic.Number WOOD SHINGLES
/ Z _ V9 A 0 V RTS
Date Q
Dat —�6 Contractor_� f 2Ill V�" OTHER(SPECIFY)
OWNER-BUILDERDECLARATIONPROPOSED APR 17 ANI
hereby affirm that an exempt from the e: Any
License Law for the finsafollowing reason.
(Sec.70315,Business and Professions or rep Code: Any city or county which requires a permit to
applicntorsuImprove,to file demolish, staair eny mentrthate,prior tnseissuance,pursuant also totheequlreethe BUILT-UP ROOF , CTYO o
applicant for such permit to Ills a Coapt r9(c mm that he Is licensedp 101,at to the provisions CITY fit' VVI't{`1171Vy
of the Contractors License Law(Chapter a(commencing with Section 7000)of Division 3 of tea _
Business and VIOl Professions Coca)or Ie1.he Is exempt therefrom and the beefs for the applicant
to ASPHALT SHINGLES L -
exemption.Anyf o t more
of Section 70315 by any applicant for a permit eubiecte the eppllcent to
a civil,penalty of not mare then five hundred dollyeesn($500),):
WOOD SHAKES❑Irks owner of the property,or to employees with wages as thea 44,Compensation,will s- ❑
the work,and the structure Is not Intended ores not apply
for ease(Sow Owner
of Business end Proles-
BionsCode:The,and
nwho does License
Lewdoesnotapplyl0anowner ofproperty who provided
dtor WOOD SHINGLES
Improves thereon,end who tloen deco workhimselffor or.If,how his Own employees,Improvement that ❑
such improvements are not Intended the
offered for sale.I(however,the buildingof pr or Improvement
is sold not bull or hin
year of for purpose
sthe ownerbulldsrwlll have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
' El 1,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(See.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who bulids or Improves thereon,and who contracts for Such projects
with a cuntiactogs)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
El am exempt under Sec, a 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:
❑1 have and will maintain a Certificate of Consent to self-insure for Workers Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit lee. ( $elSrrllC J-f--�
❑I have and will maintain Workara Compensation Insurance,as required by Section 3700 of
Cod / L/I O
-the Labor Code,for the performance of the work for which this permit Is Issued.My Worker'sd�
Compensation Insurance carrier and
'Policy number are: �6v�,.(J(J' Total
Carrier Jr��/ C /—IJnJ C] Policy No. L2v�> PE AUTHORIZATIO DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' Cyd off O
COMPENSATION INSURANCE N.C. 4
-(This section need not be Completed if the permit Is for one hundred Coils ($100)or lase.) �—4
I certify that In the performance of the work for which this permit Is Issueq I$hall not employ
any person In any manner so as to become subject to the Workers'Compensation Lewa of Cell- All roots all be inspected prior to any roofing material being
forms' install .'If a roof is installed without first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If.after making this Certificate of Exemption,you should become Applicant understands and will comply with all non
Subject to the Workers'Com ensation provisions of the Labor Cotler point
with such provisions or this permit shelba deemed revoked, you must forthwith comply source regulations. p y
I certify that I have read this application and stale that the above Information Is correct.I agree
to comply with ell 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-
spection purposes. �J /�y �
(We)agree to save;expenses
and keep harmless wa cc City ai Cupertino against liabilities,ence ,�f,/(/ �Q Li.G'4/� 7
judgments,costa and expenses which may In any way accrue against said City In consequence SIGNATURE OF APPLICANT DAT
of the granting of this permit.
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