R 5659•
OFFICE COPY
0
NUMBERR- 5659
APPLICATION FOR CITY OF CUPERTINO
INSPECTION DIVISION PERMIT EXPIRATION
REROOFPERMIT (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
22\ D OrC�Qr�
O
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
J ` 1\+ /1 1/ / C t A , I
YES ❑ IF yes —1 understand that a Class A
NAME_— YLA WnsW
mof assembly is required.
NO Initial I.C.B.O. N
2z1�� Orchard
EXISTING ROOF COVERING
ADDRESS
PHONE 9041- qq(o- I kloCv
NUMBER OF EXISTING COVERINGS
y eS
CONTRACTOR'S
NAME Res�ns�ble Rn�Fw�a \�C
TO BE REMOVED TO BE RETAINED
, .
ADDRESS Q (� #�
CITYBZIP_ 110 N.. f4eD0(-i Min,liw c!03
TYPE OF ROOF COVERING
EXISTING
(050- gi -to�5I
PHONE -
BUILT-UP ROOF ❑
LICENSE
NUMBER
ASPHALT SHINGLES ❑
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under of Chapter 9 Section
provisions (commencing with
7000) of DIVlslon 3 of the Business and Professions Code, and my license is In lull farce and
enact. 3a8Aq
Class S Lla Number "1�I
/
WOOD SHINGLES ElLicense �T
2i slblte 'Q.000
Data Ci Contractor fLe5Nn
OTHER (SPECIFY) V
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Commodes License Law for the following reason.
7031.5, Business
PROPOSED 2 31997
ll//
OcT
(Sec. and Professions Code: Any city or county which requires a permit to
construct, all er, Improve, demolish, or repair any structure, prior to Its issuance, also requires the
BUILT-UP ROOF 1:1applicant
for Such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Law (Chapter g (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 SHINGLE BY:
exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
-
a clvll penalty of not more than five hundred dollars ($500),):
El 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 Profes-
sions Code: The Contractor's License Law does not apply to an owner of property who builds 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 sale. If, however, the building or Improvement
is sold within one year of completion, the owner-bullder will have the burden of proving that he did
build or Improve for purpose of sale.).
OTHER (SPECIFY) El
❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct
the project (Sec. 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 builds or Improves thereon, and who contracts for such projects
with a contractor(S) licensed pursuant to the Contractors License Law.
C]I am exempt untler Sec, ,B 8 R C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner out.
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION
PERMIT FEE
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,
for by Section
l0 22 �,
/`
�� U�, .00
Building/77
Buildin
as provided 3700 of the Labor Code, for the performance of me work for which this
permit) Issued.
Seismic / 3 0
eve antl will maintain Workers Compensation Insurance, as required by Section 3700 of
-the CCCabor Cotle, far the performance of the work for which this permit IS Issued. My Worker's
Compensation insurance carrier and Policy number are:
/
Total `
t�� /r��,L)%� —t rr GG
Carrier`,0`c'e1� F ale Policy No.N`- 111 JJ
PERMIT AUTHORIZATION
DATE
CERTIFIcA'rb OF EXEMPTION FROM WORKERS'
-..�]
/ a a -
eA �f
G '-23
COMPENSATION INSURANCE NC.0
(This section need not be completed If the permit Is for one hundred dollars ($100) or less.)
I certify that In the performance of the work for which this permit Is Issued. I Shall not employ
V
((
All roofs shall be inspected prior to any roofing material being
any parson In any manner so as to become subject to the workers' compensation Laws of can-
°`nla.
installed. If a roof is installed without first obtaining an
Date 201 q1 Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If, after 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
pP p y p
with such provisions or this permit Shelf; be deemed revoked.
SOUfCe 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.
ep (We) purposes.
(We) agree to save, and keep harmless me Clry of Cupertino egalnet sequence
t/�]
^l/ I ��
said Ci
judgments, costa and expenses winch may in any way accrue against said City in consequence
peIndemnityesw
of the granting of this permit. �
I /
NATURE 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
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