R 4804 (2) PERMIT R_ 48 0 4
APPLICATION FOR CITY OF CUPERTINO NUMBER _J
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN DAYS PERMIT ISSUANCE OR
WI DAYSS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'Sl of wC t 5� HAZARDOUS FIRE AREA
1 J �-p VES .❑ It yes understand that a Class A
NAME �ai1—.� 119 C roof assembly is required.
`S u Los;
L -g � Cf Te��/�•.S,
I D NO
Inifa
l I.C.B.O.N
ADDRESS 1-05 adh!a SS
TING ROOF CO
PHONE At& NUMBER OF EXISTING CO GS
NERACUVTO BE REMOVED TO BE RETAINED
AM
ADDRESS , 1 P ��� �.�. , r TYPE OF ROOF COVERING
CITY 8 ZIP U / Q Q V EXISTING
PHONE 7� I 41s- L I ` l BUILT-UP ROOF ❑
LICENSE 21
NUMBER 1 1 Q ASPHALTSHINGLES 1:1
LICENSED CONTRACTORS DECLARATION
hereby affirm toff I em licensed under provisions of Chapter p(commencing with Section WOOD SHAKES
7000)of Division 3 0l the Business and Professions Code,and my license to In lull farce and
effect. ` b WOOD SHINGLES El
License Class Lic.Number I o 1
Data � ) contractor OTHER(SPECIFY) 4t ❑
OWNER-BUILDER DECLARATION PROPOSED �rT
I hereby affirm that I am exempt from the Contractors License Law for the following reef
(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 required the BUILT-up ROOF,, . 4'fYp
❑
applicant for such permit to file a signed statement that he Is Ile ed pursuant to the provisions
of the Contractors License Law(Chapter p(commencing with S M 000)of Division 3 of the
Business and Professions Cade)or that he is union p thorefJ part d e basis for the alleged ASPHALT SHINGLES'.L."
U ❑
exemption.Any violation of Section 7031.5 by any 1 1{, a ublects the applicant to
e civil penalty of not more than live hundred tlo�ISre,($50 -.
❑I,as owner of the property,or my am with Mdp r sole compensation,will do WOOD SHAKES ❑
the work,and the structure is not intended Or dffered 1 .7044,Business and Profes-
sions Code:The Contractors License an aq. wrier ofproperty who build
sor yy00DSHINGLES ❑
improves thereon,and who does sue oWy, o roup is own employees.provided that rrT /— )}�J� ��
is sushi w1thin one ts year of coIntended
p ndep the
rater. 111 ever,burdehe n
prong that he the OTHER(SPECIFY) gif le _% `^'t
notprovement
sold bull or
one yearofpurpose
athr r-builder wll6heve the burtlen of proving that he tlitl T;
le
build or Improve for purpose of sale:).
❑I,as owner of the property,am exclusfvel pnlacting with licensed contractors to construct 2001- 2)
Jp,
the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO. U `
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
I am exempt under Sec. ,B$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, BUIIdinp--
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this ILLI �, 's,�
permit is issued. �,J �I C 2 (I.vv Seismic
❑1 have and will maintain Workers Compensation Insurance,as required by Section 3700 of I J /_T
the Labor Code,for the performance of the work for which this permit is Issued.My Workers
Compenecgpp,n naur arse carri�er end�Polls number ere: _ cJ�7 Total
Carder J ! Arm-- Policy NoQL-KL—n �Ko / PERMIT AUTHORIZATION DATE
` CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.[] �+
(This section need not be completed If the permit Is for one hundred dollars($100)or lees.) U
I cartlly that In the performance of the work for which this permit Is Issued,I$hall not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Call. All roots shelf be inspected prior to any roofing material being
to in t installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It,alter making this Certificate of Exemption,you should become
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith 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.)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 tole city to enter upon the above-mentioned property for In. yp�� ((���
apache)purposes. ���,.XJM % U 7�7
(We)spree to leve,Indemnify and keep harmless the City of Cupertino against Iequelea,
of the gran costs and expenses which may In any way accrue epelnet said Cly In consequence
• onnegrannnponhlepermit. SIGNATURE 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
nFFIOF Cnpv