R 5718 PERMIT q_ 5718 .
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
/ 4946 _9 6f KA",3 -R.A C4 y Cv-P$,iQT/ND 7 S 0/Y RESIDENTIAL I COMMERCIAL OTHER
OWNER'S , ' - I - HAZARDOUS FIRE AREA
,NAME—1'1 f N #jx r q £ g j"_ -� {,c p7 Fj YES ❑ If yes-I understand that a Class A
roof assembly is required.
pp NO C] Initial .I.C.B4O.g
ADDRESS-19966 G�. 44 K'M Aft P ILAC-f - EXISTING ROOF COVERING
PHONE. NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
SNAME TO BE REMOVED SU AK/3 TO BE RETAINED
ADDRESSTYPE OF ROOF COVERING
CITYBZIP 39Y CIM 134 6/64 9b I aI�
EXISTING
PHONE Q 71_- Y y s r BUILT-UP ROOF ❑ (�
LICENSE
NUMBER 6"13001 ASPHALT SHINGLES
LICENSED
underCONTRACTORSsof Chapter 9(N
hereby affirm that 1 em Business
licensed under provisions of Chapter B(commenting with Section WOOD SHAKES
]000)of Division 3 of the Buelnese antl Professions Code,and my license is
In full lone and ,
effect.
C './ 9 6/3490/ WOOD SHINGLES ❑
Cleanse Claes Llc.Number
/�/7.Y/97 AceSAAf0A/SR&VICIM6Lne, OTHER(SPECIFY) ❑
Oeta Contractor
OWNER-BUILDER DECLARATION PROPOSED P I D
Iq
I hereby affirm that I em exempt from the Contractor's License Lew for the following reason
(Sec.7031.5,Business and Professions Coda: Any city or county which requires s permit to
construct,alter,Improve,demolish,or repairany structure,prior to Its Issuance,also requires the BUILT-UP ROOF ❑
ofapplicanttCo for such permit a flaw a signed statement that it licensed pursuant to the provisions �� �}p�Aorn
of the ss and Contractor's License Law(Chapter h(commencingIsexpt with Section 7000)of for the 3 0l the _III 11W YI
•
exemption,
entl Professions Code)or that he la exempt therefrom and the baste for the alleged ASPHALT SHINGLES
a civil penalty
naltyofolt ion more
Section 7031.5 by hundrdllyapplicantforeparmlt subjects the applicant to ) ❑ /�,
e civil,as ow of not more than floe y employees
yeesdollars(h wage: CITY 1 ' 6UP-blgji')INU
❑I,as owner of the property,or to ded oyeee with wages astheir.7 sole Business
and will Profes-
sions WOOD SHAKE$ TJ
the work,entl Ina structure le not Intentletl ores not for eels(Sec,]044, ropertsa and uildsprovesth:The Contractor's License Lewd to an his
employers,who
rovidedeor WOOD SHINGLES ❑
Improves thereon,and who does such work himself or through his own employees,provided ant
such Improvements are not Intended or offered for sale. ill however,the en of pr or Improvement T
0tbuild sold or hin
provne e for
sale.).
Owner-builtlerwlll have the burden of proving that he tlltl OTHER(SPECIFY) ® /{MAXI r,c.
not build or Improve for purpose of sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors 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 comrectons)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
El am exempt under Sec, ,B 8 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: ..�
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Building(/ _
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit Is Issued. / ,AYOO
A]'f have and will maintain Worker's Compensation Insurance,as required by Section 3700 of / 7 [o Seismic
th bar Code,for the performance of the work for which this permit Is Issued.My Worker's �D
Compensation Inaurencey c-arrielIr end Policy number are: Total /'�
CarrierRF PW13r:r�LMa1QMIlrfy kO,OAA-"" /.2939//01 PER ORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.I]
(Tele section need not performance completed If the parmlt Is for one hundretl e(Salo)or lees.) r-
I carps,that In maneersosto of the work for which W permit Is mpehIssued, hall not oraptoy
any person In any manner so ea to became subject to the Workers'Compen ft n Lawe of C toy All roof all be inspected prior to any roofing material being
fornix. installed. If a roof is installed without first obtaining an
Date s�i VIP 9 ApplicantTT
r inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,atter making Ihla Ce Illcate
of Exempt n,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the labor Code,you moat forthwith comply
PP p y
with such provisions or this permit shall be deemed revokedsource 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 law.relating to building construction,and All roof coverings to be ISIS or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes.
(We)
(We)agree tocreate save,penseslw and keep harmless tea Clty ai Cupertino against Ilebllltles, KMI r�Z y/97
of the gran ingof and expenses which may In any way aurae against said City In consequence
• of the granting of anis permit, SIGNATURE OF APPLICANTT�
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