R 5019Ob
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PERMIT R- 5 019
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 160 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
&
'000"2z2 3
RESIDENTI COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
YES ❑ If yes - I understand that a Class A
NAME
roof assembly is required.
NO ❑ Initial I.C.B.O. N
ADDRESSIIJZ2
EXISTING ROOF COVERING
PHONE �05-21,ao
NUMBER OF EXISTING COVERINGS
CONTRA TOR'S
NAME S
TO BE REMOVED TO BE RETAINED
ADDRESS
QQ
TYPE OF ROOF COVERING
CITY & ZIP
EXISTING
'
PHONE8'_/2-33BUILT-UP
ROOF
LICENSE /
NUMBER
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter B (commencing with Section
7000) of Division 3 of the Business and Professions Code, nd my license is In lull force and
WOOD SHAKES ❑ -2
effect. ppp
�+
WOOD SHINGLES 7�
License Class Lie. Number
OTHER (SPECIFY) ❑
Date Contractor
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Lew for the following reason.
PROPOSED
(Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to
-
construe t,alter, Improve, demolish, or repair any structure, prior to Its Issuance, also requires the
BUILT-UP ROOF '❑ -
appllcant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractors License Law (Chapter S (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
exemption. Any violation of Section 7031.5 by any applicant for a permit sublacts the applicant to
ASPHALT SHINGLES AUG X31996
a civil penalty of not more than five hundred dollars ($500).):
❑I, 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 eels (Sec. 7044, Business and Prolesi
I I Ut- yam, I mj
sions Code: The Contractor's License Lew does not apply to an owner of property who builds or
Improves thereon, and who does such work himself or through his own employees, provided that
WOOD SHINGLES ❑
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) a 1
not build or Improve for purpose of sale.),
❑ I, all owner of the property, em exclusively contracting with licensed contractors to construct
the project (Sec. 7044, Business and Praise one Code: The Contractors License Law does not
5' f L
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 Contractor's License Law.
❑ I am exempt under Sec. ,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;
❑ I have and will maintain a Certificate of Consent to soil -insure for Workers Compensation,
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
Building
g
permitis Issued.
have Workers
,,• dql PO
seismic
and will maintain
L or Code, for the f the for
of the this
for Insurance, as required by Section 3700 's
/ /J/ OQQ
-the performance work
work which permit Is Issued. My Worker's
Compens Ion I sur a carrier and Policy number are:`{
Carrier 0 PoseyNo.//✓/,' �k l/tJ75;
..7III
Total
PERMIT AUTHORIZATION
DATE
CERT KATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.p
(This section need not be completed If the permit Is for one hundred dollars ($100) 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 Cell.
fornia.
installed. If a roof is installed without first obtaining an
Data O ", 5-9 0 Applicant f �i�
inspection, I agree to remove all new materials for inspection.
subject to the WorrkeICE TO APPLICANT: mpensatiorn provisions oftheicateLabor Code, you muspforthwith lcecome
comply
Applicant understands .and will comply with all non point
with such provisions or this permit shall; be deemed revoked,
SOUTCO regulations.
I cantly that I have read this application and state that the above information is correct. I agree
to comply with all city and county Ordinances and State taws relating to building construction, and
All roof coverI to be class "C"or better.
hereby authorize representatives of this city to enter upon the abovermentiuned property for in.
spection purposes.
(Wel agree to save, indemnify and keep harmless the City of Cupertino against liabilities,
C
-Z,� ` 6
jutl menta, costs and expenses which may In any way accrue against veld City In consequence
of IRs granting of this permit.
SIGNATURE OF APPLICANT DATE
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 ACCESSTO ROOF -SHALL BE PROVIDED FOR INSPECTION
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