99100089 99ic�o�'�
APPLICATION FOR CITY OF CUPERTINO NUM
INSPECTION DIVISION PERM IT 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.
BUILDING ADDRESS
of 0 S 8 3aQa. �ittil�.�
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
nn � YES C] Ifyes
–I understand that a Claw A
NAME cQ.CJ roof asserrlbly Is required.
(� 140 ❑ Irtltial I.C.B.O.
ADDRESS /a/A g r, C bit •SQACL�%0 EXISTING ROOF COVERING
PHONL` #0 "S 7 NUMBER OF EXISTING COVERINGS '
CONTRA R'S /
e TO BE REMOVED TO BE RETAINED
NAME 7-t4. i�
ADDRESS/�A� � /' ^ ✓ TYP(,OEROOFCOVE RING
arvazl / /�O)')'11� �A.oW EXISTING
PHONE l'��QO �6a7SI/ J
BUILT-UP ROOFjj.. 0,.T 1 &01999 D
LICENSE /p II
NUMBER by ASPHALT SHIN j LIES
ICENSED CONTRACTORS DECLARATION
I hereby afro that I am licensed under pravls ohs of Chapter 0(commencing with Section WOOD SHAKEELk
]000)of DNIsloo 3 of the Business arta Prolessions Cade,and my license R In full force and
effect.
WOOD SHINGLES
Ucense Cpy Q Us Numbor 4
Date cmtracton OTHER(SPECIFY) ❑ /
OWNER-BUILDER DECI-ARATIC4PROPOSED ,
I hereby affirm that I em exempt from the Contractor's License Law for the bllowing reesm.
(Sec.7Wt.5,Business and Professions Code: Any city or county which requires a per milt to
construct,alter,improve,sell or repair any Structure,priorto its issuancealso requires the BUILT-UP ROOF ❑
eppil.t for such permit to file a signed statement that he Is Ilcansed pumuani to the provisions - A
of the Contractors License Law(Chapter g(commencing with Section 7")of Division 3 of the t'-
Business and Prolesamns Code)or that he Is exempt therefrom and the basis for the Alleged -ASPHALT SHINGLES 44;1 Y'
exemption.Arty vlolatlon of Section 7031.5 by any eppllcant lore permlt subjecta the applicant to
a civil penalty of not moue than flue hundred dollars $50D.): WOOD SHAKES
❑ e ih ol}�f Dr m{4e r pensetion,will do - ❑
the h tru a(9rw1 in 7 nese and Proles-
elona e: ant, pr,@L�d e n 1 n arty who builds or WOOD SHINGLES ❑
Impr ea hi ees,provided that
such Improvomenls are not Intended or offered for sale.If,however,the bulltllnp or Improvement
is sola wltN eye f Iwi r of prodng that he da OTHER(SPECIFY) ❑ y1d Ci�X
Per bullas rove s fl .
❑I,ea er oft al v Mt contractaa to construct
their, a s onAZI35110 Oconee law does not PROVIDE I.C.B.O.REPORT NO.
Apply to an owner of property who builds aImproves thereon,and who contracts for such projects
wim t n u to n Ic w,
m rr � i �� � .fathisreeson 'PROVIDE MFGR.INSTALLATION SPECS.
6wnA a L'--t i X77 1
WORKER'S COMPENSATION DECIAFATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under Perelly of perjury ane of the following diclamidon:
❑1 have and will maintain a CoMficate of Consent to selkmsure for Worker's Compensation, �d Building
as prwde t for by Section 37M of me Labor Code,for the performance of the work for which this
permit Is hound. .1s
!V/(lave and will damned Workers Compensalion lnwnance,as required by Section 3700 of /a / /3i Seismic
ttme ffarbor Cade,for the performance of the work for wNch INS pound Is Issued.My Workers
Cumpense�tion,lly�surance Farrle7end Policy(`�'mbar ere: - Total
Carrier .l�i�. T �C. Policy No57/_?F_/07 3 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C43
(This sectio"need rot be competed If the permit Is for one hundred dollen($100)or less.)
I erbfy that So the perfamnermce of the wei for which this peril is issued,I Shall not employ
any pence In any nonan so a to became ti to the waken'Cunpermatun Iaws of call- All roofs shall be inspected prior to any roofing material being
fanla. installed. If a roof Is installed without first obtaining an
Dale Applicant inspection,I agree to remove all new materials for inspection.
NOTI TO PO NT: II,after making mus Certifl a of EMemptbq you should become Applicant understands and will comply with all non int
subject to the Workers'Co ensatfon protielms of the Labor Code,you must forthwith comply - pp P Y
with such provisions or this permit shell bo doomed revakatl. Source regulations
I cerGN that I have read this Application and slate that the above information Is correct.I agree
to comply with all sly and county adlnencea antl state laws relating to building construction,and All roof coverings to be class'C"or better.
hereby authorize reprexnlalives of this clry to inter upon the abomementioned property for in-spection purposes.
(We)agree to save, Indemnity and loop harmless the City of Cupertino Agana,IlabWties, 4
judgmeri costa and expense which may In any way accrue against said City In consequence
of the granting of this perms. SIGNATURE 9F 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
OFFICE COPY