R 5122ii
OFFICE COPY
PERMIT R_ 512 2
APPLICATION FOR CITY OF CUPERTINO NUMBER
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.
BUILDINGG/
ADDRESS
e
RESIDENTIAL_ COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
q • �_
• I_ AAP
(21
YES ❑ If yes I understand that. Class A
NAME V`�titi,C.,
s
root assembly is required.
NO ❑ Initial I.C.B.0.8
EXISTING ROOF COVERING
ADDRESS-�— •
PHONE
NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
�1^
NAME
f J �.
TO BE REMOVED TO BE RETAINED
ADDRESS '.?,,
CITY BZIP.
TYPE OF ROOF COVERING
EXISTING
BUILT-UP ROOF El
p G
PHONE �7" n 39 O � 9 •
CENSE
NUMBER 'ryQ 9qJ
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter g (commencing with Section
7000) Division 3 the Business Professions
WOOD SHAKES
of of and Code, and my license Is In lull force and
effect.
LicenseCleda +� Lie. Number OTC/ �
,
WOOD SHINGLES ❑
n
—
OTHER (SPECIFY)
Data Cant ac
OWNER-SULDEOrDECLARATION
PROPOSED
I hereby affirm that I am exempt from the Contractors License Law for the following reason.
(Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to
construct, alter, improve,demolish, or repair any structure, prior to its issuance, also requires the
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
BUILT-UP ROOF AUG° 1996
of the Contractor's License Law (Chapter B (Commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he Is exempt therefrom and rho basis for the alleged
ASPHALT SHINGLES ❑
exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
CITY
a civil penalty of not more than five hundred dollars ($500).):
01, as owner of the properly, or my employees with wages as their sole compensation, will do
Vi Vsh- x-1,I❑W
WOOD SHAKES ❑
the work, and the structure Is not Intended or offered for sale (Sac. 7044, Business and Profes-
slons of
The Contractors License workhi does not orthroto an ghhiso own
property who provibuildded
Improv Improves
Improves thereon, and who does deco work himself or Through his own employees, ed teat
at
WOOD SHINGLES ❑
such Improvements are not intended or for dale. however, the Improvement
or Improvement
fatsold ownerffered
ill
owner -builder will have the buroen of proving that he did
an of pr
OTHER (SPECIFY) ❑
build or
not bulitl or Improve for purpose al Bale.).
prove for purpose of
01, as owner of the property, am exclusively contracting with licensed contractors to construct
the project (Sec. 7044, Business and Profession; Code: The Contractor's License Law does not
PROVIDE I.C.B.O. REPORT NO.
apply to an owner of property who builds or Improved thereon, and who contracts for such projects
with phtracloge) licensed perdu m to the Contractors License Law,
2,2 exempt under Sec. ,B $ P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
owns` Date
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION
PERMIT FEE
I here affirm under penalty of perjury one of rhe following tleclarotion:
01 via and will _.'main a Cenifall a of Consent to i elf -Insure lorworkere Compensation,
by
Building
a; Pro vI a Section 3]00 of the Labor Code . for the performance of 'he work for which this
PermitI uatl.
❑ 1 h and will m-inroln Worker'a Compensation Inauranee, ed raqulrad by Section 3]0001
the Lab e, lar the penormance of the work for which this permitla issued My Worker's
`9— / �/
�l
2000
+--'—'—�'�
Seismic O
7 Fr-
Campaneatlon urance carrier end Policy number are:
V O�{O f�
Total
Carrier Policy No.
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
��
1
COMPENSATION INSURANCE N.C.O
(This section need not be completed If the permit Is for one hundred dollars ell 0) or less.)
Q 7 CL
�• 6. y6
I certify that In the performance of the work for which this permit Is Issued, I shell not employ
All roofs shall be inspected prior to any roo g m erial being
any parson in any manner sees to become sub' 1 m the Worl d' Compensation Laws of can-
fertile 1y �ny'/ �
installed. If a roof is installed without first obtaining an
oare(ljL� Applicen
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If, after making this Cerrlficar of Exemtion, you should become
subject to the Workers' Compensation provisions of the La or Code, you must forthwith comply
Applicant understands and will comply
PP ply with all non point
with such provisions or this permit shall be deemed revoked,
Source regulations.
I certify that I have read this application and state that the above information le correct. I agree
laws
AI "C"or
to
to comply with all city and county ordinances and state relating to building Co
hereby authorize representatives of this city toenter upon the above-mentioned property for In-
reon purposed.
OOf Cove If sto be class better.
(We) agree to save, indemnity and keep harmless the City Of Cupertino against liabilities,
judgments, Coats and expenses which may in any way accrue against said CityIn consequence
of me granting of this permit.
IG ATUR OF APPLICANT DATE
PRE-INSPECTION:r hlp.
PLYWOOD:
IN -PROGRESS:
INSP. DATE ^`l
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