99110173 (2) 7�3
PERM
-- APPLICATION FOR CITY OF CUPERTINO Nu
INSPECTION DIVISION ,TION
REROOF PERMIT (408)777-3'2'28 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
ZORESIDENTIAL COMMERCIAL OTHER
OWNER'S 1.7 HAZARDOUS FIRE AREA
NAME (d/ P (�[. /�Tf'I� ` VES ❑ If �mbly s required.
NAME
a55 A
NO ❑ Inlhal I.C.B.O.k
ADDRESS
l9 9zen to EXISTING ROOF COVERING�.�7 ^
PHONE 7L_24 NUMBER OF EXISTING COVERINGS r//�
CONTRACTORn
NAME v✓y y [�/( , ( TO BE REMOVED TO BE RETAINED
ADDRESS Z TYPE OF ROOF COVERING
CITY 8 ZIP
EXISTING
PHONE Z/O 971 -1777 BUILT-UP ROOF
LICENSE
NUMBER ASPHALT SHINGLES ❑
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 Code,and my license Is in of force and
effect' q INGLES
License/CIa39 d-,s�_ C2.6 Lic.Number d QIn
!/
Date Cant ractorD rMitr- PECIFY)
OWNER-BUILDER - f�TlO ED
I hereby affirm that I am exempt from the Contractor's License Law for the loll a
(Sec.7031.5,Business and Professions Cotle: Any city pount hi
construct,alter,improve,demolish,or repair any structure, or to it a ca, s - P ROOF� /'Z\ yGL 1 I
applicant for such permit to file a signed statement that ha Ikense8 ant 1 r i s 17 / x—tel
of the Contractor's License Law(Chapter 9(commencing wSaaj f e
Business and Professions Code)or that he is exempt Ner fI'din an the basis for the alleged HIN ENO
/ xi (� (� I�
exemption.Any violation of Section 7031.5 by any applicant fora u e lic I V 2 t7 (�A
a civil penalty of not more than five hundred dollars( 1 KE 9
I,as owner of the property,or my employees wit vita .1 m d
the work,and the structure is not intended or offeredS a R
sions Code:The Contractor's License Law does not a y t property who builds ar WOOD SHINGL-E✓v ❑
improves thereon,and who does such work himself or through his own employees,provided that
suchimprovements 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.).
❑1,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 contractods)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.lar 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, /_ + qp, S-�"p Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Seismic
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of �^ S
the Labor Code,for the performance of the work for which this permit is issued.My Worker's Total
Compensation Insurance�c/a,rrier o d Policy number are: /.'A/pq
Carrierili! 11�' -6� Pokey No.A,✓ r /�6??T0 PERMIT AUTHORIZATION DATE
CERTIFICATE CIF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed if t mil is for one huntlred dollars($100)or less.) `�J �J r l'j —�
I certify that in the performance of the ork fo which this permit' ued.I shall not employ G
any person in any manner so as to beco o sabi t to me wor r amp ealmn Lewa m Cali- All roofs shall be inspected prior to any roofing material eing
fornix. installed. If a roof is installed without first obtaining an
Date I f-2)-5 91 Apr I nl inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,arm this Certificate of Exemption,you should become A IIC t understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Coda,you must lorthwith comply pP P y P
with such provisions or this permit shall be deemed revoked. Sou IS r ulations.
I certify that I have read this application and state that the above information is correbt. agree
to comply with all city and county ordinances and state laws relating to building construction,ono At roof Co Brings O Or better
hereby authorize representatives of this city to enter upon the abovo-mentionetl property for in- y`'
spection purposes. 11-2, -�
(We)agree to save,indemnity and keep harmless the City of Cupertino against lieoililies,
judgments,costs and expenses which may in any way accrue against said City in consequence SIGNATURE OF APPLICANT DATE
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