R 4926 PERMIT R_ 4 9 2 6
APPLICATION FOR CITY of CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (406)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
• 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
v y Qr RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ It yes—I understand that a Class A
NAME (2d rL,/ /j2 n P //Q� roof assembry is required.
NO ❑ Initial I.C.B.O.M
ADDRESS //Z,5- (e�'�•1T� - r�y� �P✓( EXISTING ROOF COVERING
PHONE
NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S
/irl� /(j TO BE REMOVED TO BE RETAINED
NAME �
ADDRESS 1�
TYPE OF ROOF
CITYBZP���/� ��(y f ✓�/M 4zEXISTING V
PHONE C'�J•-s t y� / BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION y�
I )of Di affirm that I em licensed ss under Professions
of Chapter 8(commencing with Section WOOD SHAKES [�T
7000)of Division 3 01 the Bualnaee end Promaelons Code,and my license Is In lull lona end
Lima. e ,3� WOOD SHINGLES L A• �' ❑ /rf-�
License Class Lic.Number p
O- OTHER(SPECIFY)MUrj 13 lbs
Date Contractor
OWNER-BUILDER OE Contractor's License
PROPOSED
(Sec�703b1,5 affirm
Business entl Peoleeslone Codt from the e: city orcountywhich lrog10 llowle Oerm80t
construct,alter,Improve,demolish,or repair any structure,prior to Its issuance.also requires the BUILT-UP ROOF ❑'x'
applicant for such permit to file a signed Statement that he Is licensed pursuant to the provisions
of the Contractor'°License Law(Chapter g(commonclnp with Section 7000)of Division 3 0f. the Business and Professions Code)or that h°Is exempt therefrom and the heel°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 five hundred dollars($500).): WOOD SHAKES
�—
❑I,as owner of the property,or my employees with wages as their sole Compensation,will do
the work,and the structure Is not intended or offered for sale(Sec.7044,Business and Profes.
Sierra Code:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑
improves 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
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 exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
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 Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
E]I em exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION P FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to selbinsure for Worker's Compensation, Bull n
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this AUG 3
permit lave and 1996' /fCo-' seismic
❑ have°ntl will maithe performance
WarnWorkers f the work
for Insurance,as required by Section Worker's's /[Vw-�
the Labor Code,for the performance of the work for which this permit Is leauatl.My Worker'°
Comp
_e_n°��aJtttfo�n,,lnLsuuranca cirri r and ollcy number are: � Total
r'
Card {dee�(,T Policy No.-g(�L /3 PERMIT AUTHORIZATION PATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.Op
(This section need not be Completed If the permit m for one hundred dollars($100)or leas.)
I certify that In the performance of the work for which this py/(ilt Is 11q2, shall not emotoy
any parson In any manner so as to become subject t°the I Ther o IfenaetIon Laws of Oak- All roofs shaff be inspected.pnor tof ny roo in• mat 'al being
f°'nl°' installed. If a roof is installed without first obtaining an
Data APPllcent inspection,I agree to remove all new materials for inspection.
NoTicE(TOAIli1FUCANT. If,aper making this locate 1 Exemption,y uld become Applicant underst s a 'II cont
subject to the Workers'Compensation provisions of Lobar Code,you must forthwith comply PP ply with all non point
with such provisions or this permit shall be tlaemed voted. Source regulatl
I Certify that 1 have read this application and°tate that the above Information Is correct.I agree
to Comply with all city and county ordinances antl&rate laws relating to building construction,and All roof cD ass"C" better.
hereby authorize representatives of this city to enter upon the above-mentioned property for Int
spection purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino sp°inst liabilities, " /
judgments,costs and expenses which may In any way accrue against Bead City n consequence
of the granting of this permit. U E 0 PPLICANT DATE
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATEINSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY