99120014 0 � 3117 -00s-
APPLICATION FOR CITY OF CUPERTINO
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(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
/oGss Ros111Olt,III ORO .
RESIDENTIAL COMMERCIAL OTHER
OWNER'S t . , '/n� HAZARDOUS FIRE AREA
W MS% W o O 91 V" P l y YES ❑ If yes s I assembly
is req that. Class A
NAME roof assembly is required.
.,Lq��., ! k NO ❑ Initial I.C.B.O.q
ADDRESS ! 1-1 —'+ + `Z Lt�1K W Os r EXISTING ROOF COVERING
PHONE �—� NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME L, C?JCsiU.A l'SV RoQril4i `vQf�lNts' TO BE REMOVED TO BE RETAINED
ADDRESS G 77 I�'l t V� c Ow �, ctiZ TYPE OF ROOF COVERING
CITY&ZIP
p EXISTING
PHONE C LuC) "1 —IZ77 BUILT-UP ROOF
LICENSE
NUMBER S6 2-0 O ASPHALTSHINGLES El
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Cade,and my license is in full force and
alfa<L �lq { WOOD SHINGLES ❑
License Class G(, , �OLic.Number `�OT t
/2L ADCs OTHER SPECIFY 1
Date Contractor W� (SPECIFY) D �,❑
�— �ER-BUILDER DECLARATION PROPOSED
hereby affirm that am exempt from the Contractor's License Lew for the following reason. DEC1(�(](]
(Sac.construct,
It Business and Professions Code: Any city or county which requires a permit to B ROOF G 1999
construct,alter,improve,to file siorrepaironentrucWre,prior toils Issuance,also requires fns
fthapplicant for such permit to file a Chaptestatement nci he is licensed 7000)
ofto the provisions
of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and violation of Code)or that he is exempt therefrom and the basis for athepp icantallegedto HING ES ❑
oxemoften.Any violation of Section 7031.8 by any applicant for a permit subjects the applicant 10
a civil penalty of not more than five hundred
employees
dollars with
wag.): WOODS
1,as owner of the property,or to employeeswith wages as their sole compensation,will Profes-
sions
work,egtl the structure a net intended ores not for sale(Sec.owner
of Business and builds
or
Code:The Contractor's License Lew does not apply to an owner o1 property whooided t or WDD LE ❑
improves thereon,and who does such work himself or through his own employees,improvement provided that
such improvements are not intended or owner-builder
for sale.ill however,the building or iimprovement /
ntbuilsold d or
movyear for purpose
cal owner-builder will have the burden of provingthat hedid OTHER(SP ❑
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.SORT NO.
apply to an owner of property who builds or improves thereon,and who contracts for such projects
with a conlractous)licensed pursuant to the Contractor's License Law, PROVIDE MFGR.INSTALLATION SPECS.
I]I am exempt under Sec. ,B 8 P.C.for this reason
Owner Date
ATIO 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 self-insure for Worker's Compensation, 1��Z-91 �� J Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. `
❑f have and will maintain Worker's Compensation Insurance,as required by Section 3700 of g Se I Il
the Labor Code,for the performance of the work for which this permit is issued.My Workers Z� m f
Compensation Insurance carrier and Policy number are: TO r
357
Carrier-( R'ILMLaWi C ' !top policy No.W�g�07 P ERM IT AUTHORIZATION DATE
CERTIFICATE OF EXIIIMPTION FROM WORKERS'
COMPENSATION INSURANCE NC.I]
(This section need not be completed if the permit is for one on re tlollare($1 el) or less.) 2 - 2-- R
I certify that in the performance of the work for which thi' rmit is all not employ
any person in any manner so as to become subject to the likes' more aalion Laws of call- All roofs shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date lZ Z/11 Applicant inspection,I agree to remove all new materials for inspection.
NOTICE#0 AF#UCANT If,offer makl s I hcate of Exe ion,you should become rpant understan an will cam I with all non point
subject to the Workers'Compensation provisions of the Labor Cotle, must forthwith comply pwith such provisins or this permit shall be deemed revoked. regulationsI certify that I have read this application antl state Nat the above information is correct,I agreeto comply with all city and county ordinances antl state laws relating to building construction,and ove 'I t0 eCl S° Orb er.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes, q
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities, I Z/T 'r�
judgments,costs and expenses which may in any way accrue against Said City in consequence
of the granting of this permit. 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
OFFICE COPY