R 5756v
0
a
OFFICE COPY
PERMIT R_-5756
NUMBER
APPLICATION FOR CITY OF CUPERTINO
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
_ WITHIN 100 DAYS OF PERMIT ISSUANCE OR
160 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
I S30 L cfvh %A -q f}V Q_
RESIDENTIAL COMMERCIAL OTHER
OWNER'S -
HAZARDOUS FIRE AREA
� ✓ Fv
NAME Vs�
VES ❑ If yes — I understand that a Class A
roof assembly is required.
NO ❑ Initial I.C.B.O. e
-
1
ADDRESS � L• -0M --la A-tr2
EXISTING ROOF COVERING
/
PHONE — 513
NUMBER OF EXISTING COVERINGS
'
�m
CONTRACTOR'S
r� ' �y7
NAME ��P7•G'N E.2 V-V2NC - Co my Its.
TO BE REMOVED TO BE RETAINED
ADDRESS p b p (� �O
'�O
TYPE OF ROOF COVERING
CITY & ZIP f dere
EXISTING
C�4- • 9Sz,3o
PHONE
BUILT-UP ROOF ❑ /
LICENSE7
NUMBER (,2q Zia
ASPHALT SHINGLES yam/
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter a (commencing with Section
WOOD SHAKES ❑
7000) of Division 3 of the Business and Professions Codo y license Is In full force and
affect.
License Claes Z'
WOOD SHINGLES ❑
-c"3� Llc.bar
l0l$9 °I
OTHER (SPECIFY) ❑
Date Contractor
OWNER -BUIL DECLARATION
PROPOSED
hereby elllrm that I em exempt from ontracmr'e License Lew to1e following reason.
(Sec. 7031.5, Business and Prpfesei Code: Any city or county which requires a permit to
construct, alter. Improve, demolls repair any structure, prior to its issuance, also requires the
1
�/
applicant for such permit to file good statement that he Is licensed pursuant to the provisions
BUILT-UP ROOF ❑
of the Commodes 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
exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
ASPHALT SHINGLES ❑
XF
e cNn penalty of not more than five hundred dollars ($500).):
❑f, as owner of the property, Of my employees with wages as their sole compeneatlon,wledo
WOOD SHAKES ❑
the work, and the structure Is not Intended or offered for sale (Sac. 7044, Business and Profen
-
sions Code: The Contractors License Law does not apply to an owner of property who builds or
Improves thereon, and who does such work himself or through Ms own employees, provided that
WOOD SHINGLES ❑
such Improvements are not Intended or offered for sale. If, however, the building or Improvement
`
Is sold within one year of completion, the owner -builder will have the burden of proving that he did
OTHER (SPECIFY) /y�'•GC' Q
not build or Improve for purpose of sale.),
S . �• s�
❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct
the project (Soc.7044. Business and Professions Code: The Contractor's License Law does not
PROVIDE I.C.B.O. REPORT NO.
apply to an owner of property who builds or Improves thereon, and who contracts for such projects
with a comractons) licensed pursuant to the Contractors License Law.
exempt under Sec. ,B & P. C. for this reason
PROVIDE MFG R. INSTALLATION SPECS.
Owneram
owner oats
APPLICATION DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm untler penalty of perjury one of the following declaration:
❑ I have and will maintain a Certificate Consent for Workers
of to saiNnsure Compensation,10
as provided for action 3700 of the Labor Code, for the performance of the work for which this
permit ie is
/ O IA
V
BUIldlnc�.�_
Seismic O
a end will maintain Worker's Compensation Insurance, as required by Section 3700 of
the aeon Code, for the performance of the work for which this permit Is Issued. My Workers
Compensation Insurance carrier and Policy number are:
1//
Total( i"77r 7 a
2piSs$s o:x tit3l0
!�
PERMIT AUTHORIZATION
DATE
Carrier PolicyNo.WL
CERTIFICATE 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 coolly that In the performance of the work for which this permit is Issued, I shall not employ
any person In any manner so as to became subject to in Workers' Compensation Laws of Call.
1
All roofs Shall be inspected prior to any roofing material being
fondle.
installed. If a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If, at making this C /lost of Exemption, you should become
subject to the Workers' Compensation provisions of III Labor Code, you must forthwith comply
Applicantand will cont ply with all non point
I29i
with such provisions or this permit shall be doomed revoked.
I certify that 1 have read this application and state that the above Information Is correct. I agree
to comply with all city and county Ordinances and state laws rotating to building construction, and
lass,"I& better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
• ep purposes.
�f(X
(We) agree to save, and may harmless the City Cupertino agelnet liabilities,
(We)
/.I /4
(/ /' CJ
expenses i wa a against
judgments, ware and expenses which may In any way accrue agelnet seitl City In consequence
ence
of the granting o1 this permit.
NT DATE
PRE -INSPECTION:
PLYWOOD:
IN -P KESS:
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
OFFICE COPY
v
0
a
OFFICE COPY
PERMIT R_-5756
NUMBER
APPLICATION FOR CITY OF CUPERTINO
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
_ WITHIN 100 DAYS OF PERMIT ISSUANCE OR
160 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
I S30 L cfvh %A -q f}V Q_
RESIDENTIAL COMMERCIAL OTHER
OWNER'S -
HAZARDOUS FIRE AREA
� ✓ Fv
NAME Vs�
VES ❑ If yes — I understand that a Class A
roof assembly is required.
NO ❑ Initial I.C.B.O. e
-
1
ADDRESS � L• -0M --la A-tr2
EXISTING ROOF COVERING
/
PHONE — 513
NUMBER OF EXISTING COVERINGS
'
�m
CONTRACTOR'S
r� ' �y7
NAME ��P7•G'N E.2 V-V2NC - Co my Its.
TO BE REMOVED TO BE RETAINED
ADDRESS p b p (� �O
'�O
TYPE OF ROOF COVERING
CITY & ZIP f dere
EXISTING
C�4- • 9Sz,3o
PHONE
BUILT-UP ROOF ❑ /
LICENSE7
NUMBER (,2q Zia
ASPHALT SHINGLES yam/
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter a (commencing with Section
WOOD SHAKES ❑
7000) of Division 3 of the Business and Professions Codo y license Is In full force and
affect.
License Claes Z'
WOOD SHINGLES ❑
-c"3� Llc.bar
l0l$9 °I
OTHER (SPECIFY) ❑
Date Contractor
OWNER -BUIL DECLARATION
PROPOSED
hereby elllrm that I em exempt from ontracmr'e License Lew to1e following reason.
(Sec. 7031.5, Business and Prpfesei Code: Any city or county which requires a permit to
construct, alter. Improve, demolls repair any structure, prior to its issuance, also requires the
1
�/
applicant for such permit to file good statement that he Is licensed pursuant to the provisions
BUILT-UP ROOF ❑
of the Commodes 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
exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
ASPHALT SHINGLES ❑
XF
e cNn penalty of not more than five hundred dollars ($500).):
❑f, as owner of the property, Of my employees with wages as their sole compeneatlon,wledo
WOOD SHAKES ❑
the work, and the structure Is not Intended or offered for sale (Sac. 7044, Business and Profen
-
sions Code: The Contractors License Law does not apply to an owner of property who builds or
Improves thereon, and who does such work himself or through Ms own employees, provided that
WOOD SHINGLES ❑
such Improvements are not Intended or offered for sale. If, however, the building or Improvement
`
Is sold within one year of completion, the owner -builder will have the burden of proving that he did
OTHER (SPECIFY) /y�'•GC' Q
not build or Improve for purpose of sale.),
S . �• s�
❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct
the project (Soc.7044. Business and Professions Code: The Contractor's License Law does not
PROVIDE I.C.B.O. REPORT NO.
apply to an owner of property who builds or Improves thereon, and who contracts for such projects
with a comractons) licensed pursuant to the Contractors License Law.
exempt under Sec. ,B & P. C. for this reason
PROVIDE MFG R. INSTALLATION SPECS.
Owneram
owner oats
APPLICATION DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm untler penalty of perjury one of the following declaration:
❑ I have and will maintain a Certificate Consent for Workers
of to saiNnsure Compensation,10
as provided for action 3700 of the Labor Code, for the performance of the work for which this
permit ie is
/ O IA
V
BUIldlnc�.�_
Seismic O
a end will maintain Worker's Compensation Insurance, as required by Section 3700 of
the aeon Code, for the performance of the work for which this permit Is Issued. My Workers
Compensation Insurance carrier and Policy number are:
1//
Total( i"77r 7 a
2piSs$s o:x tit3l0
!�
PERMIT AUTHORIZATION
DATE
Carrier PolicyNo.WL
CERTIFICATE 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 coolly that In the performance of the work for which this permit is Issued, I shall not employ
any person In any manner so as to became subject to in Workers' Compensation Laws of Call.
1
All roofs Shall be inspected prior to any roofing material being
fondle.
installed. If a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If, at making this C /lost of Exemption, you should become
subject to the Workers' Compensation provisions of III Labor Code, you must forthwith comply
Applicantand will cont ply with all non point
I29i
with such provisions or this permit shall be doomed revoked.
I certify that 1 have read this application and state that the above Information Is correct. I agree
to comply with all city and county Ordinances and state laws rotating to building construction, and
lass,"I& better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
• ep purposes.
�f(X
(We) agree to save, and may harmless the City Cupertino agelnet liabilities,
(We)
/.I /4
(/ /' CJ
expenses i wa a against
judgments, ware and expenses which may In any way accrue agelnet seitl City In consequence
ence
of the granting o1 this permit.
NT DATE
PRE -INSPECTION:
PLYWOOD:
IN -P KESS:
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
OFFICE COPY