R 49920
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OFFICE COPY
PERMIT R_ 4 9 9 2
NUMBER
APPLICATION FOR CITY of CUPERTINO
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK 19 NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
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RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE ARE
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YES ❑ It yes — I understand that a Class A
NAME I 1 r.�
root assembly is required.
NO ❑ Initial I.C.B.O. M
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EXISTING ROOF COVERING
ADDRESS
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1
NUMBER OF EXISTING COVERINGS
PHONE
CONTRACTO"R''Sx�
1/I/ 1 r.—ti, 7 _. (�
NAME— I • `U r �^ LN" ����++VV
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TO BE REMOVED TO BE RETAINED
ADDRESS L.�. /� (
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C T
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TYPE OF ROOF COVERING
CITY 8 ZIP 1c) �)
W—hG e. a -y z- `�• +
EXISTING
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7
PHONE _2;2-
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BUILT-UP ROOF
LICENSE
NUMBER ,
ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
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 full force and
affect. ( G
I
WOOD SHINGLES ¢�
License Class ` LIc. Number `^
OTHER (SPECIFY)
ZI —C( Cj `
Date Contractor
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contr for's License Law for the following reason.
PROPOSED
'
(Sec. 7031.5, Business and Professions Code: An ci or county which requires a permit to
construct,alter, improve, demolish, or repalreIn 9In,e`, prior to Its issuance, also requires the
applicant for such permit to Ills a signed atatament'thet IhJ(censetl pursuant to the provisions
Hit
BUILT-UP ROOF JUL ��1996
of the Contractor's License Lew (Chapter 9 (ca In h action 7000) of Division 3 of the
Business and Professions Code) or that he is e r in and the basis for the
exemption. Any Section 7031 by 1 'permlt
ASPHALT SHINGLESI-1 y (%r GUY
,alleged
violation of any for subjects the applicant to
a civil panaity of not more loan Ilve hu red dollar . .
s, rT I Infu
❑I, es owner of the property, or employ Kwages as their sola compensation, will do
the
WOOD SHAKES
work, end the structure le na(.I d r d for sale (Sec. 7044, Business and Proles.
alone Code: The Contractor's LIE eIL eg not apply to an owner of property who builds or
Improves thereon, end who dog r tllmsell or through his own employees, provided that
WOOD SHINGLES
such Improvements ere not Inle pep4red for sale. If, however, the building or Improvement
Is sold have
within one year of completio)h erQwnerbuilder will the burden of proving that he dict
OTHER SPECIFY
(SPECIFY)
not build or Improve for purpose of s w..
dI
❑1, as owner of the property, am exclusively contracting with licensed contractors to construct
the project (Sec. Business and Professions Coda: The Contractors License Lew does
PROVIDE I.C.B.O. REPORT NO.
not
apply to an owner of property who builds or Improves thereon, and who contracts for such projects
with a contractor(s) licensed pursuant to the Contractor's License Law.
EJI am exempt under Sac. ,B 8 P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner oats
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE VALUATION
PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
V V
❑ 1 have and will maintain a Certificate of Consent to self -insure for Worker's Compensation,
Building 1.717.
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
permit ie$.
❑ I have and will maintain Worker's Compensation Insurance, as required by Section 3700 of
Cod
the Labor Code, for the performance Of the work for which this permit Is issued. My Worker's
si
Seismic
Compens!t on Iq�ura^{�ce�rrler�'d Pollcy number are:
5 %
Total ��
Carrier it lV„ fO Policy Noe � n t
PER AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' 00006l
COMPENSATION INSURANCE N.C.❑
(This section need not be completed If the permit Is for one hundred dollars (8100) or less.)
I certify that In the performance of the work for which this permit Is issued, I shall not employ
All roofs shall be Inspected prior to any roofing material being
any person In any manner so as to become subject to the Workers' Compensation Laws of Call.
fornla.
installed. If a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: 11, shat making this C1111111cate of Exemption, you should become
subject to the Workers' Compensation provisions of the Labor Coda, you must forthwith comply
Applicant understands and will complywith all non point
with such provisions or this permit shall be deemed revoked.
source regulations.
I certify that I have react this application and stale that the above Information Is correct. I agree
to comply with all city and county ordinances and state laws relating to building conamIctlon,and
All roof r into be "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,
judgments, costs and expenses which may In any way accrue against said City In consequence
STGNATWRE OF APP NT 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