R-4899•
a
OFFICE COPY
PERMIT1.
4899
-APPLICATION FOR CITY OF CUPERTINO NUMBERR_
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 160 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
Z OCl 1 6
C e. d
RESIDENTIAL COMMERCIAL_Z-OTHER
OWNER'S
HAZARDOUS FIRE AREA
YES ❑ Ryes —embly ad. ClassA
NAME / J�r-� .�% �Q/yff//(///t//
isrequirtand
root assembly Is required.
NO F Initial LC.B.O. k
�_A,P S �i�/ G"T
EXISTING ROOF
ADDRESS
iCOVERING
PHONE Q 736 -/7-3(7
NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
/J
NAME /Y L/�,(//� ea 11c_ //
TO BE REMOVED TO BE RETAINED
./
ADDRESS ?C ��/
TYPE OF ROOF COVERING
CITY BZip— /IS c.J-3
'
EXISTING
(SAN C-1�j3C � GA rJ S//Z
PHONE
BUILT-UP ROOFLICENSE
NUMBER ) Z /
ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am Ilcensed under provisions of Chapter 9 (commencing with Section
WOOD SHAKES
7000) of Division 3 of the Business and Professions Cotle, and my license Is In full force and
affect' 7 ycsZ�/�
License Class LIC. Number
WOOD SHINGLES ❑
G�3-��
OTHER
OTHER (SPECIFY) ❑
Date Contractor /PG2:7/%//1�
PROPOSED
OWNER -BUILDER DECLA ION
I hereby affirm that I am exempt from the Contractor's License Law for the allowing reason.
(Sac. 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 �l
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Law (Chapter 9 (commencing with Seaton 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
e civil penalty of not more than five hundred dollars ($500).):
I, as owner of the property, or my employees with wages as their sole compensation, will do
r] 1,
SHAKES ❑
the work, and the structure 19 not Intended or offered for sale (Sec. 7044, Business and Profes-
sions Code: The Contractor's License Lew 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 -builder will have the burden of proving that he did
OTHER (SPECIFY) ❑
not 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 such projects
with a contortions) licensed pursuant to the Contractor's License Law.
PROVIDE MFGR. INSTALLATION SPECS.
❑ 1 em exempt under Sec. ,B 8 P. C. for this reason
OwnerDate
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION
PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
711 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
BUlldl
permit Is issued.
❑ I haveand will elrf Werke/a Insurance, as required by 3700
/ O/
F3/
SeismI C
the Labor Code, for the performance of the work for which thl9 permit Is Issued, My Worker's
Compensation
Total
lnauran ecerrler Polic number are:
PERMIT AUTHORIZATION
TE
Carrier °` Policy No_71 - z�y - 4 $�
CERTIFICATE OF EXEMPTION FROM WORKERS'
_
COMPENSATION INSURANCE N.C.I]
(This section need not be completed It the perm m hundred dol rs (3100) or lees.)
certlty that In the performance of thew r which iha permit la Is ed, hail not em toy
fan-
a
any person any m ser 90 e9 t0 be a subject to orkers' pensatawa f
All roofs shall e' specte oofi aterial sing
fornix.
installed. If a roof is installed without first obtaining an
Oat s L G+ Ap
inyyyysppeettttc....taatiaio��o�n,, I agree to remove all new materials for inspection.
you ahoua become
NOT to TO AP LICAN io making this Certlllcet p de, you
subject to the Workers' Compensation provisions or Code, you must forthwith comply
(fg and will comply W11h all non OIOt
p Y P
with such provisions or this permit si,be dee d rave d.
OUrce egulations.
certify that have reed this application and st the above Information la correct. e
to Comply with all city and county ordinances and state laws relating to building conatructl and
All r00 COVerI be Class" "or better.
hereby authorize representatives of this city to enter upon the above-mentlonatl prop for In-
spection purposes.
(We) agree to save, Indemnify and keep harmless the City of Cupertino again
-
,Ilabllltles,
judgments, coats and expenses which may In any way accrue against said City In consequence
SI F 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