R 4853•
0
OFFICE COPY
PERMIT R_ 4853
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.
BUILDING ADDRESS
Z /'+
2 b J V CAS 5�1.
T LW TDIJ
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
y� -
PANC901-`e
SEs ❑ If that ClassA
NAME 1 -5Mr
is requiredtand
roof assembly is required. .
NO ElInitial I.C.B.O. P
ill
G,3 C."rtI -7w 37-
EXISTING ROOF COVERING
ADDRESS 0 l,"P,
(2�-I
1 7-5-
NUMBER OF EXISTING COVERINGS
PHONE CICS)
TO BE REMOVED 5 S TO BE RETAINED
CONTRACTOR'S
4t Nlt,� 0 r Jb /
NAME !LJ lei
ADDRESS r'
TYPE OF ROOF COVERING
CITY & ZIP G rLt f 6
EXISTING
PHONE 5Z t(3k —%2 7
BUILT-UP ROOF ❑
LICENSE
NUMBER Z 2,y 3
ASPHALTSHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions or Chapter 9 (commencing with Section
WOOD SHAKES ❑
7000) of Division 3 or the Business and Professions Code, and my license is in full force and
enact.
� Y L y2Y 3
WOOD SHINGLES El
Class Lic. Number
Datey'2L—i Contractor �dYG �
OTHER (SPECIFY) 11b
OWNER-BUILDERDECL
I hereby affirm that I am exempt from the Contractor's License Lew for the following reason.
PROPOSED
(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
BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that is licensed pursuant to the provisions
of the Contractor's License Law (Chapter 9 (commonsrJ action 7000) of Division 3 of the
Business Professions Code) Is
and or that he exedpl the r6m and the basis for the alleged
ASPHALT SHINGLES
exemption. Any violation of Section 7031.5 by spirit icantf ermit subjects the applicant to
e civil penalty of not more then flue huntlretl�tSltars 50 .)
EJ 1, as owner of the property, or my em loyees wit a their sole compensation, will do
WOOD SHAKES ❑
the work, and the structure la not Inlentla�or olio §ala (Sec. 7044, Business and Prolea-
o pN to an owner of property who builds or
Improves thereon, and who does sucHithrough his own employees, provided that
slonsCotle: The Contractor's Licensgl
WOOD SHINGLES ❑
such Improvements are not Intended ala. If, however, the bulltling or improvement
las Its within one year of completion,untler will have the burden of proving that he did
OTHER (SPECIFY) ❑
not build or Improve for purpose of se❑
I, a° owner of the property, am aly contracting with licensed contractors to construct
the project (See. 7044, Business and Professions Code: The Contractors License Law does not
PROVIDE I.C.B.O. REPORT NO.
apply to an owner or property who builds or Improves thereon, and who contracts for such projects
with a contractor(s) licensed pursuant to the Contractor's License Law.
❑ 1 am exempt under See. ,B 6 P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
OwnerDate
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION
PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑ 1 have and will maintain a Certificate of Consent to self -Insure for Worker's Compensation,
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
/
Building4
permit is issued.
AM have and will maintain Workers Compensation Insurance, as required by Section 3700 of
�1T QV
i
Seismic %O
the bor Code, for the performance or the work for which this permit (e issued. My Worker's
Compensation Insurance car ler ane Policy umbo/rare:
Total
Pr^K`ra�'� ^�" p70 /
PERMIT AUTHORIZATION
DATE
Carrier Policy No. "
CERTIFICATE OF EXEMPTION FROM WORKERS'
L Z—y
COMPENSATION INSURANCE N.C.
(This section need not be completed if the permit Is for one hundred dollars ($100) or less.)
J
Joe- 0q)-'72>'_- (,J�,,�r•
I certify that In the performance or the work for which this permit Is Issued. I shall not employ
All roofs shall be inspected prl o y roofing material being
any person In any manner so as to become subject to the Workers' Compensation Laws of Call-
form..installed.
If a roof is installed without first obtaining an
Date - Applicant
inspectiori, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: 11, after making this Certificate of Exemption, you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
with such provisions or this permit shalfba deemed revoked.
Applicant understands and will coat I wi h all non point
pP A/ p y p
Source regU ns. R�Lr :�T
I certify, that I have read this application and state that the above Information Is correct. I agree
_/L 0
to comply with all city and county ordinances and stale laws relating to building construction, and
All roofs er' gs be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposea.
(We) agree to save, indemnity and keep harmless the City of Cupertino against liabilities.
T _%
/oe j9 A..%x7A.-<.CL r;: ;� ^ ir
judgments. costs and expenses which may In any way accrue against said City.consequence
SIGNAI UHL OF APPLICANT ATE
of the granting of this permit.
PRE -INSPECTION:
PLYWOOD:
IN-PROGRESApR 211996
INSP. DATE
INSP.—DATE—
INSP.—DATE
-TEAR OFF INSPECTION:
BATTENS:
FINAL: CIIr I.,,-
,XfINSP.
INSP.DATE
INSP. DATE
INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY