R-5597•
E
PERMIT
5597
APPLICATION FOR CITY of cuPERTINo NUMB RR-
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED.
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
1p0/'o
,
RESIDENTIAL COMMERCIAL OTHER '
OWNERSnn
-
FIRE AREA
----'' ,, --
YES ❑ yeaI understand that a Class A
NAME '
w//WL
roof nssemhby is required
roof
NO ❑ Initial- LC.B.O. R
'T
ADDRESS
EXISTING ROOF COVERING
per— (,
PHONE . OO Z �� L L 0
NUMBER OF EXISTING COVERINGS '
CONTRACTOR'
TO BE REMOVED / TO BE RETAINED
NAME 1614,
ADDRESS ' ! C� _ �.
v
TYPE OF ROOF COVERING
CITY & ZIP ?
EXISTING
q 3a
PHONE —
BUILT-UP ROOF.
LICENSE
NUMBER T O2 7Oo
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provatons of Chapter B (commencing with Section
WOOD AKES ❑
7000) of DMelon 3 of the Business and Pate dilom Code. and my litems is In full torte and
'
effect.
` O
WO GLES ❑
Jc. Number
Dcense Class `_ ✓��
dd
OTHER (SP ❑
Date Z0.— contractor
OWNER-BUILDERDECLAAA
I hereby affirm that I em exempt from the Contractors Ucenee Law for me fo7owing reason.
PROPOSED
(Sec. 7031.5, Business and Professions Code: Any dry or county which requires a permit to
construct, eller, Improve, derrollsh, or repair any structure, prior to Its Issuance, also requires the
t
BUILT-UP R
applicant for such permit to file a signed statement that M Is licensed pursuant to the irmislons'
of the Contractors Ucenw Law (Chapter 9 (commencing with Section 7000) of DMI 3 of the
Business and Professions Code) or )hat he is exempt therefrom anal the bests for the allegetl
ASPHALT.SHIN ❑
exemption. Any violation of Section 7031.5 by any applicant far a permit subjects the eppt cont to
CC
dull penalty of not more than f,ta humbled dollars ($500).):
I, as owner of the property, Or my with wages as thein sole compernatlon, will do
❑ employees'
Sr^p
WOOD PII
E]e
Cl' 9
the work, end the structure Is not Intended or offered for sale (Sec. 7044, Business and Profes-
stns Code: The Contractors License Lew does not appy to an owner of property who bulks or
WOOD HINGE rD
improves thereon, and who does such worem
himself or through his own eployees, prodri that
❑
such Improvements are not Intended or offered for sale. If, howarer, the bulli ing or Improvement
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Is sold within one year of completion, the owner-bulber will have the burden of proving that he did
OTHF ECFV) ❑
not build or Improve for purpose of sale.).
"sJ
❑I, as r me property, em mutuaNely contracting with licensed contractors to construct
Me proleol (Sec. 70", Business and Professions Code: The CuntractV8 License Law does not
PROVIDE I,E.B'.•b. REPORT NO.
apply to an owner of property who builds or Improves thereon, and who cormacta for such prolects
`'\1
with a contractorts) licensed pursuant to the Contractor's ucensa law.
PROVIDE MFGR. INSTALLATION SPECS.
❑ 1 am exempt under Sec. ,B 6 P. C. far this reason
Owner Date
APPLICATION DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECI-ARATION
I hereby affhm under penalty of perjury one of the following declension: -
❑ 1 have and maintain a ate Of Consent to e9161neure for Workers Compensation,this
//
Building
S of the
perpmlis Issuetl. Section 3]00 of me Labor Cade, far me perbrmeroe of me work for which this
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LL o
r�
(7kl he's art will malntaln Workers Compensatlon Insurance, as required by Section 3700 of
Seismic �lL
ih bon Code, far me performance of the work for which this permit Is Issued. My Workers
mer Po
Center
7 p
Totallam[-._y=
euon ce en arere:. ��—q7-1/^ `
4_�L(�{+ ' "
Carrier' No.
PERMIT AUTHORIZATION
DATE
FPolicyROM
CERTIFICATE OF EXEMPTION FROM WORKERS'
!�
J, !`
INSURANCE
COMPENSATION INSURANCE 100)N.CJ0o
section need motor completed H the permit Is for one hundred lasso
IThio
sued,) shall nor
thatInthe performance of dor work far which this gamic, is issued, shell not empty
All roof^ shall be inspected prior to any roofing material being
shall
person
emq peraen In any nor eo ee to becortte cabled to,he W n a company non Lawn of Cell=
Iomla.
X
installed. If a roof is installed without first obtaining an
Data 6 App am
inspection, I agree to remove all new materials for inspection.
NOTICE O APPLICANT: It, after making this Certifies of Examptlon, you should babwne
subject to the Workers' Compensation ppro slops of the m Cade, you must forthwith comply
Applicant understands and will comply with all non point
PP P Y P
with such provisions or this pammn shel,be teemed revoked.
Source regulations. '
, I tartly that I have read this application and state that the above Informedon Is correct, l agree
tocomply with 0city add county ordinances and state laws relating to bcilldrig corsvucdan,and
hereby authorize representatives Of this city to enter upon the above-mentioned property lot In-
-
All roof "or better.
spection purposes.
;veer agsclass°
�/��
(We) agree to save, Indemnity and keep hermleas the City of Cupertino e9alnst Ilabllklea,
judgments, torts and expenee awhich may In any way accrue against said Cry In consequence
SIGNATURE OF APPLICANT DATE
of the renting of thio 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