R-4707Ak
0
•
OFFICE COPY
PERMIT R_ 4 7 7
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
O6
RESIDENTIAL)C COMMERCIAL OTHER
OWNER'S -
HAZARDOUS FIRE AREA
F, �r / CAJ�1
YES ❑ If yes — I understand that a Class A "
NAME l� _ /
O roof assembly is required.
N Initial I.C.B.O. #
,{4
Plc) ''S f Q� Z&S*43 ?J M2
EXISTING ROOF COVERING
ADDRESS H_ CAz
NUMBER OF EXISTING COVERINGS
PHONE
TO BE REMOVED TO BE RETAINED
CONTRACTOR'S -- �^
AVV �
NAME
COVERING
DDRESS 00 l/a/Y� (�-- 7 5/ e1
fm
CITY & ZIP �7'
EXISTING .
C
PHONE JL23 �' 9Sr��
BUILT -UP ROOF
LIGN Ep�eSLTE-
ASPHALTSHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
WOOD SHAKES ❑
7000) of Division 3 of the Business and Professions Code, and my license is In full force and
effect. `
�_ (� n !)
WOOD SHINGLES El
License Class Lic. Number 7, e
OTHER (SPECIFY) ❑
Date Contractor
OWNER - BUILDER DECLARATION
PROPOSED
I hereby affirm that I em exempt from the Contractors License Law for the following reason.
(Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to
construct, alter, improve, demolish, orrepair any structure, prior to Its Issuance, also requires the
BUILT -UP ROOF
applicant for such permit to file a signed statement that he Is licensed pursuant to the provislons
. of the Contractor's License Lew (Chapter 9 (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
ASPHALT SHINGLES ❑
exemption. Any violation of Section 7031.5 by any op Ilcant forapermit subjects the applicant to
a civil penalty of not more than five hundred delete ( 50o pp
❑ I, as owner of the proper%t1rmy a Ibyees vi wages es their sot m ation, will do
the work, and the structure le not Intantle r far r sale (Sec. 70444{��{CC��ppu s antl Proles-
WOOD SHAKES ❑
'
sions Code: The Contractors License Le e I to wnerW�rbper who buildsor
Improves does that
WOOD SHINGLES ❑
thereon, and who suc r m or rou ow empl Improvement
improvements or of Into tl o ale. If, a the bull fig or Improvement
such
Is sold within one ye r f o I to owner till er wYFh set burden of proving that he did
OTHER (SPECIFY) ❑
not build or Improve r Po f ale I
❑I,es ownerofthe ,amexclusive c t acting with licensed contractors to construct
the project (Sec. 7044, s1 as end Profess) n ode: The Contractor's License Law does not
PROVIDE I.C.B.O. REPORT NO.
applytoenownerofprop 1 he bullds or improves thereon, and who contracts for such projects
with a contractor(s) licensed pursuant to the Contractors License Law.
PROVIDE MFGR. INSTALLATION SPECS.
❑ 1 em exempt under Sac. ,B & P. C. for this reason
Owner Date
APPLICATION PAjTE
VALUATION
PERMI FEE
WORKER'S COMPENSATION DECLARATION
_
C
I hereby affirm under penalty of perjury one of the following declaration:
1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation.
as provided for by Section 3700 of the Labor Code, for the Performance of the work for which this
, QA
�t
�QL
Building
permit is issued.
199s
Seismic
❑ 1 have and will maintain Worker's Compensation Insurance, es required by Section 3700 of
(,'
the Labor Code, for the performance of the work for which this permit Is Issued. My Workers
i/NcL
�/' +]//
-the lnsurarncre carriers olicy number ere:
`'1I /yy
1
Total
57/-75-
PERMITAUTHORI ION
DATE
Carrier `-',` Policy No.
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 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 Can-
All roof.^. shall be inspected prior to any roofing tWaletlal being
forma.
installed. If a roof is installed without first obtaining an
Data Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It, alter making this Certificate of Exemption, you should become
Applicant understands and will comply with all non point
pP P Y P
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
with such provisions or this permit shalQbe 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 roW -es erings to be class" "or better.
hereby authorize representatives of this city to enter upon the above - mentioned property for In-
spection purposes.
keep harmless City Cupertino liabilities,
(We) agree to save. Indemnity and the of against
judgments, costs and expenses which may In any way accrue against said City in consequence
SIGNATURE F APPLICANT DAT
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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY