R 4769•
0
OFFICE COPY
PERIT
NUMBER R- 4769
APPLICATION FOR CITY OF CUPERTINO
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
pp
O O N `IS L N
tO .GSI "1 k
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
n T - a
e-IZ �J K'r `
YES ❑ 210t I andreq that. Class A
NAME ' r \ 1"J t V G "1 N Ali
as is
root assembly is required.
assembly
NO ❑ Initial I.C.B.O. #
•
�(o S LOI.QIIQ S L
EXISTING ROOF COVERING
ADDRESS 4 F-L� -N "
NUMBER OF EXISTING COVERINGS /
PHONE
CONTRACTOR'S
l w /(�
NAME ) A-cr N ��
TO BE REMOVED TO BE RETAINED
ADDRESSQTYPE
POO, P>OK 3S
OF
CITY &ZIP 2' W\.S.Gr"Cb,30
EXISTING
❑ �/
BUILT-UP ROOFLICENSE
PHONE -7-7
NUMBER (o Z 2-S
ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B (commencing with Section
WOOD SHAKES
7000) of Division 3 of the Business and Professions Code, and my license is In lull force and
effect'
�'-3�j
WOOD SHINGLES ❑
License Cleae uc. Number
[}— t7:Qi1a
OTHER (SPECIFY) ❑
Date Contractor
OWNER -BUIL ECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
PROPOSED
(Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to
construct after, 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 he Is licensed pursuant to the provisions
of the Contractor's License Law (Chapter g (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he Is exempt therefrom and the basis for the alleged
ASPHALT SHINGLES ❑
exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than live hundred dollars ($500).):
'
❑1, as owner of the property, or my employees with wages as their sole compensation, will do
WOOD SHAKES ❑
the work, and the structure Is not Intended or offered for sale (Sec, 7044, Business and Profes.
alone Code: The Contractor's License Low does not apply to an owner of property who builds or
Improves
WOOD SHINGLES ❑
thereon, and who does such work himself or through his own employees, provided that
such improvements are not Intended or offered for sale. If, however, the building or improvement
0 F &0-
~
Q —
Is sold within one year of completion, the owner -builder will have the burden of proving that he did
OTHER (SPECIFY)
not build or Improve for purpose of sale.).
❑I, as owner of the property, am exclusiv, codd,,,,((��r''es hl ice need contractors to construct
the project (see. 7044, Business and Profs rtes rte Contraetor'e License Lew dose not
PROVIDE LC.B.O. REPORT NO.
apply to an owner of properly who builds or ov(6et a on, and who con ale for such projects
r
with a contractor(e) licensed pursuant totII e on rector. License Lew.
❑ 1 am exempt under Sac. ,B & P, C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner ° Data
APPLICATION DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑ I have and will maintain a Certificate of Consent to sell -insure for Worker's Compensation,
asprovide or by Section 3700 of the Labor Code, for the performance of the work for which this
permlti sued.
rrN
J vl
Building
eve antl will maintain Worker's Compensation Insurance, as required by Section 3700 of
/g��/V•�/jJr
H
$eISrI11C
_the Labor Code, for the performance of the work for which this permit la Issued. My Worker's
CompanerQion InsMuranncce�carrier and Policy number are:
2 7��
Total
Cl
y
✓7�1' /-C �Nt�
��-
Carrier PagayNo.� •io�99-7G
(,PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
vryV
COMPENSATION INSURANCE N C
(This section need not be completed If the permit Is for one hundred dollars ($100) or lase.)
I certify that In the performance of the work for which this permit Is Issued, 1 shall not employ
All roofn shall be inspected prior to any roofing material being
any person In any manner so as to become a ject to to won w' Compensation Laws of Cain
fornia.
installed. If a roof is installed without first obtaining an
Data Appllcen .
inspection, I agree to remove all new materials for inspection.
-
NOTICE TO APPLICANT, subject to the Workers' Compefnselion previ. after sionis of theLaborCape, ycate of ou you ehhwitould become
you must forthwith comply
Applicant understands and will comply with all non point
P Y
with such provisions or this permit ehalfjbe tleemetl revoked.
SOUfCO regulations.
I certify that I have road this application and state that the above Information Is correct. I agree
to comply with all city and county ordinances and state laws relating to building construction, and
Allr COVer is to aSS"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes.
(We) agree to save, Indemnify and keep harmless the City of Cupertino against liabilities,
judgments, coats and expenses which may In any way accrue against said City in consequence
of the 0ranting of this permit.
GNATURE O P NT DATE
PRE -INSPECTION:
PLYWOOD:
IN -P OGRESS:
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