R-46560
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OFFICE COPY
PERMIT R_ 4656
APPLICATION FOR CITY OF CUPERTINO NUMBER
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` �GrT1 �iAw�l�
RESIDENTIAL COMMERCIAL – OTHER
0 R's
HAZARDOUS FIRE AREA
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DES ❑ If yes I tend that. Class A
that
NAMEA I WlP !�4
roof assembly isand
s mbly i
NO Initial I.C.B.O. tl
/t j
$y,� 1S2MF_
EXISTING ROOF COVERING
ADDRESS �%� 7ri7 t49f-j yin)
G —
NUMBER OF EXISTING COVERINGS
PHONE
'
TO BE REMOVED 2 70 BE RETAINED
CONTRACTOR'S
C� )� ,Q�
NAME TTT J
F
TYPE OF ROOF COVERING
ADDRESS ztl�,/
CITY & ZIP 7 H ® l t i�r L��
EXISTING
G�
36 —/JCJ S 2
PHONE �� "'
BUILT -UP ROOF ❑
LICENSE
NUMBER
ASPHALT SHINGLES
NSE
LIC D CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
WOOD SHAKES ❑
70 00) of Division 3 of the Business and Professions Code, and my license Is In full force and
effect.
c–
WOOD SHINGLES ❑
License Clas Uc. Number
D
OTHER (SPECIFY) ❑
Contractor
Data Contractor
OWNER- BUILDER DECLARATION
PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to
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construct, alter, improve, demolish, or repair any structure, prior to Its issuance, also requires the
BUILT-UP ROOF . 'Y®
applicant for such permit to file a signed statement that he Is licensed pursuant to the provislons
of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
O T C.0
Business and Professions Code) or that he is exempt therefrom and me basis for the alleged -
ASPHALT SHINGLE �p
exemption. Any violation of Section 7 031.5 by any applicant for a permit subjects the applicant to
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a clvli penalty of not more than five hundred dollar ($50o).g
❑ I, as owner of the property, or mpe loyees Ith wages as their sole compensation, will do
WOOD SHAKES v' as
/
the work, and the structure is not intend or o for sale (Sec. 7044, Business and Profes.
- sions Code: The Cont ctois Ucens a e n a to an owner of property who builds or
apply p p ty
WOOD SHINGLES h
�(�❑
Improves thereon, en o oe u o or thro his own employees, provided that
such improvements r Ot 1 tl fo e. II, o e building Or improvement
is sold within one ye tl ,th�o vner -builtl rw vburtlen of proving that he did
OTHER (SPECIFY) ❑
not build or improve for pose of sale..
❑I, es owner of the arty. am excl s lycontracting with licensed contractors to construct
the protect (Sec. ]044, siness and Pr le sions Coda: 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 contractors) licensed pursuant to the Contractor's License Law.
PROVIDE MFGR. INSTALLATION SPECS.
O 1 am exempt under Sec. ,B & P. C. for this reason
Owner Date
APPLICATION DATE
VALUATION
PERMIT F E
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 aelbinsure for Worker's Compensation,
Building
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
'
permiyis issued.
Seismic
have antl will maintain Workers Compensation Insurance, as required by Section 3700
the Labor Coda, for the performance of the work for which this permit is Issued, My Worker's
Total
compensation l sure eGCarrler and Policy number are:
/G [y
�
PERMITAUTHORIZAT
DATE
�
Carrier 2��C LuE94 PaI Icy NO./O —L
CER�ATE OF'*EMPTION FROM WORKERS'
Ilk
COMPENSATION INSURANCE N.C.I]
311
(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 shell not employ
any person in any manner so as to become subject to the Workers' Compensation Laws of Cell.
All roofs shall be inspected prior to any roofing TMterial being
mrnia. i
installed. If a roof is installed without first obtaining an
Data 0 Applicant iQ UL // (r1LY
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If, after makin Certlllcale of Exemption, you should become
Applicant understands and will comply Wlih all non Oln
P Y P
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
with such or this shall be deemed revoked.
source regulations.
provisions permit
1 certify that I have reed this application and state that the above Information Is correct I agree
All to "C "o ID
to comply with all city and county ordinances and state laws relating to building construction, and
roof coverings aclass efts
hereby authorize representatives of this city to enter upon the above - mentioned property for In-
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spection purposes.
1
(We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities,
judgments, costs and expenses which may In any way accrue against said Cily In consequence
S G E O APPL CA T DATE
of the granting of this permit.
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