R 4915 (2) APPLICATION FOR CITY OF CUPERTINO NUMBER R- 4 915
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUJLDING ADDRESS \ �/
Z2 L 1 O SAhSY� �.V l �UV RESIDENTIAL-K— OTHER
OWNER'S HAZARDOUS FIRE AREA
(� YES ❑ If yes–I understand that a Class A
` NAME pir 1 f 7C\1 Y\C_�:; roof aasemby,Is required.
u n NO Intal I.C.B.O.e
ADDRESS-_2a qo S.Y\+0s 110_"`Irh w"JV EXISTING ROOF COVERING
PHONE (40a) (:e " 4Zo `d NUMBER OF EXISTING COVERINGS
CONTRACTOR'S (�
NAME kc 1 I,V\2. 2 OOr -y,$ CO TO BE REMOVED TO BE RETAINED
ADDRESS C TYPE OF ROOF COVERING
,cITY B ZIP 3!J5 /(_Ji✓I _
Son ci_eC/M G EXISTING
PHONE I "$04 231 – O'2–O G BUILT-UP ROOF ❑
LICENSE � S� � 3G7 ASPHALT SHINGLES
NUMBER ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and
effect. C—39 WOOD SHINGLES
License Class Lic,Number 2 I�0 ❑
Date ���C�96 Contractor /' e 3; 24 in 26 OTHER (SPECIFY) pp❑t
OWNER BUILDER DECLAATION
I hereby affirm that 1 am exempt from the Contractors License w for the following reason. PROPOSED
(Sec.7031.5, ,improsa end Professions Code: Any city or coon uxo requires a permit toconsBUILT-UP ROOF JUN 1 q]1996
(Sec.703 .5, Improve, nd demolish,Professions
rant'eAnycity orlartol7 uppnce,aro requi
res mthe
applicant for such permit to file a signed statement i he is licensomirlarant to the provislons
of the Contractor's License Law(Chapter 8(corp ancing with Sect[ D)of Division 3 of the
. Business and Professions Code)or that he, exempt Ih fro ale for the alleged ASPHALT SHINGLES C UU, t t.l illu
exemption,Any violation of Section 7031.55yanyappllcant r a subjects the applicant to VIII V ��
a civil penalty of not more than five hundre ollafs($500).);
❑1,
as ownerotthe properly,or m(e ayeas withw etnelreole compensation,will do WOOD SHAKES ❑
the work,end the etrumura is not Intend d or as o(Sec.7044,Business and Protea-
aionsCode;TneCanlmctoreLicenap a l ply to an owner at property who builds or WOOD SHINGLES
Improves thereon,antl who does such war a' r through his own employees,provided that ❑ �z/._r�`
such Improvements are not Intended or o re r sale.If,however,the building or Improvement ww�Ay ry
is sold within one year of completion,the ova�er builder will have the burden of proving that he did OTHER(SPECIFY) GY/srV
not build or Improve for purpose of sate.).
[11,as owner of the property,am exclualvely contracting with IlcensBd contractors to construct
the project(Sec.7044,Business and Professions Code:The Contraoor's License Lew 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 contmctons)licensed pursuant to the Contractor's License Law. PROVIDE MFGR. INSTALLATION SPECS.
1 am exempt under Sec. ,S a 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 salt-insure for Worker's Compensation,
this /O/350,66
5 Q 66 Building ./�-�'
the provided lor and ill mainain a of the Labor Code,Consent
the performance for
Work for ensation, (0 Y ( ✓
permit Is Issued.
/46❑1 have and will maintain Workers Compensation Insurance,as required by Section 3700 of Seismic
,the Labor Code,for the performance of the work for which this permit is issued.My Workers
Compensation Insurance sealer end Policy number are: Total
Carrier �'1N6 ..(/–lr/� , Policy No. 13056��9L PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Tile section need not be completed If the permit is for one hundred dollars($100)100)or lase.) �
I codify that in the performance of the work for which this permit Is Issued,I shall not employ Dip
any person in any manner so as to become subject to the Workers'Compensation Laws of Cali- All roots shall be inspected prior to any roofing material being
forma. // installed. If a roof is installed without first obtaining an
Date�eCYly— Applicant -sKu�h c PYbB=I: Co inspection,I agree to remove all new materials for inspection.
subject too the Compensation l,after provisions of thelcale of Laborr Code,yolu must forthwithcecome
omplyomply Applicant understands and will comply with all non point
with such provisions or this permit shaIPbe deemed revoked. source regulations.
I certify that I have read this application and sate 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-
spection purposes.
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities,
ofthe granting of this permit,dgments,costs and expenses which may In any way accrue against sold City in consequence SIGNATURE OF APPLICANT 1 DAZE
. 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 COPV