R 5580 PERMIT R_
APPLICATION FORMSPECTIONTY OF CUPERTINO NUMBER 5580
DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-9228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS / �A
VF RESIDENTIAY` " COMMERCIAL OTHER
OWNERI HAZARDOUS FIRE AREA
.!f_ 4AA� /f4 ,O&7jo_ f J- YES ❑ If yes—assembly
is req that. Class A
NAME 1T (J �,./ 6� / roof assembly is required.
NO Initial I.C.B.O.p
ADDRESS
7S C h,4 A V E . EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S TO T p
NAME ! 1Y/ /L o CD I v �1 BE REMOVED TO BE RETAINED
ADDRESS ,.0 ,/ L � TYPE OF ROOF COVERING
CITY B ZIP-2/b 534-.t�' �BSF /Y'UL t,�. 9ra .
�/`l _p EXISTING
PHONE(/(, 9 77-- 0,W 0 BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em 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 full force and
effect.
o
Z
❑
License Claes � � � Lic.Number O / � WOOD SHINGLES
Date___�ZL contrecmr ®® OTHER(SPECIFY) ❑
OWNER BUILDER DECLARATION PROPOSED
hereby aHJumBu that em exempt from the e: Any city License Lew for the following a reason.
(Sec.70315,alter,Impr ve end olish,Professionsrep Coda: Any city er county which requires a permll to
conatrunLoru Improve,to file signeepatreny mentrthat he prior tnse l pursuae.at theproreethe BUILT-UP ROOF ❑
of the Contractor's for etch permll to flaw a signed statement that he le Ilcens o pursuant to the prb of the
o the ssanPo License Law(Chapter B(commencing with Section]000)of for the 3 of the pS
Business and violation of Code)or that he Is exempt therefrom and the heels for the scant to ASPHALT$HINGLCJN
exemption,Any f violation more
of than
len hundred
by any sapplicant($5 ).for a permit subjects the applicant to
a evil penalty of not more leen five y employees
dollars(h wages
age: WOOD SHA*
❑I,k,and wner
structure
not
tended oyeeered weBeeas(Sec.their sole compensation,sndPries. ^ ❑
the work,entl the structure Ie not Intended ores not for eels(Sec.owner
property
end Proles t+Y{TX /sem
Ilona Code:The,an Who does
Law doesnalapply toanowner ofproperty who builds or WOOD St'71 Al f,$LES & }y,� ❑
Improves thereon,entl who does deco work himself or Through ee own employees,Improvement
mproprovided ant '�7°
such Improvements are not completion,
the
oared for tela.ill however,the en of pr or Improehmect �.
not
Is tbuild or
year of for purpose
sthe ownao-bulltler will have the burden of proving tett he aid OTHER(SPECIf�/y A� ❑
not bulla or Improve ler puppets of seat.). I�•Y
❑1,as c owner of the property,am exclusivelyProfessions
Code:
T withlicensedContractors
rs Lice sere to construct
the project(Sec. ofprperty Business hendProfessionsCode:TheandwhocotractsfoLewdadsnot PROVIDE LC.B.O.REPO NO.
apply to c ntownerof property who anti orImproves thereon,entl who contracts for such projects
with a comexem t licensee pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑I em exempt under Sec. ,B 6 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERM
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: ,,,
❑ idea and will maintain 37 I Certificate of Content to self-insure performa for Worker's Compensation, Bull g
e6 E)I have
tl for by Section 3700 of the Leber Code,for the performance of the work for whichansa ithison, `
permltl sued Set c
eve end will maintain Worker's Compensation Insurance,as required by Section 3700 of G / (/A^
the bar Code,for the performance of the work for which this permit is lasuetl.My Worker's O/�O/9� �! �� Total
Compensation Insurance carrier and Polley number are: o`l
Carrier YF61A.140 Policy No.-4o69I« PERMIT AUTHORIZATION DATE
CERTIFICATE FROM WORKERS'
COMPENSATION INSURANCE
N.C.I] -Jam— sxv
(This section need not be completed If the permit It for one hundred dollars($100)or lees.)
I certify 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 become subject to the Workers'Compensation Laws of Call. All roofs shall be inspected prior to any roofing material being
fornix' installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
subje�toEheOWoP Workers'Compen,after sation making
is of thelcate of Laborr Code,Exemption,
musttforthwith lbecome
amply Applicant understands and will comply with all non point
with such provisions or this permit shell be deemed revoked. Source regulations.
I certify 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 laws relating to building construction,and All roof covering to be clan C' or better.
hereby authorize representatives of this city to enter upon the above-mentioned propety.for In.
spection purposes. ��
(We)agree to save, Indemnify and keep harmless the City of Cupertino agelnat liabilities,
judgments,costa and expenses which may In any way accrue against said City n consequence
of the granting of this permit. SIGOF APPLICANT AT
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
OFFICE COPY .