R 5164•
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R_ 5164
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
/d 3 7 O azljae � lei
�
.
RESIDENTIAL COMMERCIAL OTHER
OWNER's
HAZARDOUS FIRE AREA
��� (/n �f�
Class A
YES If off
NAME / "�r'�"" "� ^ QHL /.��
assembly is requihed.
NO Initial I.C.B.O. #
�'7-3'?-
ADDRESS e-�
EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS /
/�
PHONE O —211(.::.
COMRA OR's
M
TO BE REMOVED TO BE RETAINED
.NAE
.
ADDRESS / �, ,,Q.
TYPE OF ROOF COVERING
/� r Q5 %���LA- �1iJ1/ ti1X
CITY 8 ZIP h
EXISTING
BUILT -UP ROOF ❑
L GQ- 9 l 0
�� -� ��
LICENSE
��
NUMBER (�
ASPHALT SHINGLES ❑ �C
WOOD SHAKES V
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I em under of Chapter g (commencing with Section
Division
7000) of Division 3 of the Sualnesa entl Profeealane Cotle, and my license Is In full lone entl
Business Professions and
effect, C3C
License Cl e e ( Lie. Number �� / /
WOOD SHINGLES ❑ -
OTHER (SPECIFY) ❑
Date .��_
OWNER- BUILDER DECLARATION
.SU LOEF
I hereby affirm that 1 am exempt Iron the License Lew for the following reason.
PROPOSED
(See. 70315, Business and
Bu e: Any
Code: Any city or county which requires a permit to
construct, alter. Improve, demolish, or rep structure, Issuance, requires the
BUILT-UP ROOF ❑
Lila
to Ilia signed statement that
that Leh
applicant for such permit Is license pursuant to the provisions
pursuant to the
of the sn and Pro License Law (Chapter h Is ex pt t eref om and 7000) of for the 3 0l the
a (Chapter r 9 (commencing Section 3 oth
Business entl Code) or that he le exempt therefrom entl the belle far the alleged
ASPHALT SHINGLES '1
ex ptio violation of
exemption. pen. Any violation of Section hundred by any applicant for a permit subjects the applicant to
to
e civil gasify of not more than five
77�� fix'
2 6 U
❑ I, as owner of the properly, or y employees yees with wage:
ayeee with wages as their Bole compensation, will do
WOOD SHAKe6EP 1996 ❑
the work, and the to ded
Is not Intended of e sale (Sec. 7044, Business entl
ontracto
s;onsCotle: The, an who License Lewdoes i poor through ghhis owner builds o-
not pp
es, who
own property
rovidedt at
Improves thereon, entl who tloee such work himself or through hie own employees, provided that
WOOD SHINGLES ❑
such Improvements are not Intended or offered for eels. II, however, the building or Improvement
Is sold within one year of completion, the owner- bulldcr will have the burden of proving that he did
OTHER (SPECIFY) E3
not build or Improve for purpose of sale.).
E] 1, as owner of the property, am exclusively contrecting with licensed contractors to construct
the project (Sec. 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 contrectoge) licensed pursuant to the Contractor's License Law,
1 am exempt under Sec. ,B 8 P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS,
Owner Date
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION
PERMIT FEE
1 hereby affirm under penalty of perjury one of the following declaration:
❑ I have and will maintain a Certificate of Consent to self-Insure Mr Worker's Compensation,
as provided for by Section 3700 of the Labor Code, for the Mr
,,..dd
/�'�y�y.� ^
Build g
performance of the work which this
permit Is leauetl.
��gc��c�eve antl will maintain Worker's COmpanaetlon lnIDUrance, es requlretl by Saetlon 3700 of!
// /'
Fb
Y�
//,500
$eISfT11C
the Lobar Cotle, for the performance of the work for which this permit la leauetl. My Workar'e
Compensation trance cerr`ler�entl�PO�licy number ere:
Total
PERMIT AUTHORIZATION
DATE
Cartler
FROMNaSERS
CERTIFICATE EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
It the
(This section need not be completed It the permit Is for one hundred tlollets ($100) or IeaaJ
100) o
1<
1 certify that in the performance of the work for which this permit Is Issued, I shell not employ
All roots 5 e inspected p for to a roofing material being
any person In any manner sc as to become subject to the Workers' Com a Laws of Call.
Ionia'
installed. If a roof is installed without first obtaining an
Date .4 FII Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE APPLICANT
subject Workers CCOmpsnaetlon provinlonle of i�rtalj�LaborCOtlemyou muetuforthwllttlhbcomply
Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed mvOkad
source regulations.
I certify that I have reed this application and state that the above Information la correct. I agree
to comply with all city and county ordinances and state laws relating to building construction, and
All roof cov ings to be Class "C "or better.
hereby authorize representatives of this city to enter upon the above - mentioned property for Im
spackon agree to
(We) agree to save, Indemnify and keep harmless the City of Cupertino epelnat liabilities,
7
judgments, costa and expenses which may In any way accrue against said City In consequence
of the granting of this permit.
SIGNATURE O 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY