00020011 a Vivol(
FNIJIMBERNIIIIIIIIIIIIIIIIINP1111117,,
ERMIT
APPLICATION FOR CITY OF'CUPERTwo
INSPECTION DIVISION' - PERMIT EXPIRATION
REROOF PERMIT' . (40$)•]77-3228 ` PERMIT EXPIRES IF WORK IS NOT STARTED
- '
WITHIN DAYS PERMIT ISSUANCE OR
'180 DAYSS FROM LAST CALLED INSPECTION.
BUILDING ADDRESSI 'I_J'I . ./u"/ r/• f\DA I .. RESIDENTIALLY 'COMMERCIAL - OTHER
owryER's HAZARDOUS FIRE AREA
NAME / I `14. If O.N. - YES ❑ If yes—I°understand that a Class A
roof assembly is required
1' --a - - NQ Initial, t' - ICBO.#
r/, -
ADDRESS I� I rur/ '�l).A6 emPeR'('II�I'0 EXISTING ROOF COVERING
PHONE V 0— '% 5151, -NUMBER OF EXISTING COVERINGS "I
CONTRACTOR,'Sp.
NAME T v �VYr'IN'uT. TOPE REMOVED TO EE RETAINED' -
ADDRESS
, lob: OaK ` _ , P F R VER
CITY B ZIP- ��nR � .
�.
'EXISTING
PHONE 409. L
' L7" • 1t"IJ
LICENSE .. r. .. R 3
BUILT-UP ROOF
� - -
NUMBER " °I ASPHALTSHINGLES " ?(�
LICENSED CONTRACTORS DECLARATION '. - 5X��
° I hereby affirm that I am licensed under provislone 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.
y/ ❑
Licenn se Class� Lic.Number -721511
` • + 1 1p1 WOOD SHINGLES
Date Contractor
�IUO T � C '�U111�'IvG� OTHER(SPECIFY) . ❑
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
construct,alter,Improve,demolish,or repair 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 provisions
of the Contractor's License Law(Chapter g(commanding with Section 7000)ofDivision 3 of the
• Business and Professions Cade)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES DC
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to.
a civil penalty of not more than five hundred dollars($500).):
01,as owner of the property,or my employees with wages as their sole compensation,will do., WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes-
sions Code:
rofes-sionsCode:The Contractor's License Law does not apply to an owner of property who builds or WOAD SHINGLES
Improves thereon,and who does such work himself or th rough his own employees,provided that . . ❑
such Improvements are not Intended or offered for sale.If,however,the building or Improvement -
Issolowlihinoneyearofcompletion,the owner-builder will have the burden of proving that he did. OTHER(SPECIFY) ❑' '
not build or Improve for purpose of sale.). - ,
p 1,as owner of the property,am exclusively contracting with licensed contractors to construct
_ the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I,C•B•O.REPORT NO.
apply to an owner of property who builds or Improves thereac,'ond who contracts for such Projects with a contractor(s)licensed pursuant to the Contractor's License Law, ,. PROVIDE MFGR.INSTALLATION SPECS.
- ❑ em exempt under Sec. ,B$P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION _
I hereby affirm under penalty,of perjury one of the following declaral;on:' -
❑1 have and will melntain a Certificate of Consent to self-insure for Worker's Compensation, 'Building
as provided for by Section 3700 of the Labor Code,far the performance of the work for which the .n"7 g
p rmd Issued. I 2 VV
have end will maintain Workar'e Compeneatlon Insurance,ea requiretl by Sectlan 3700 of ZI 2V V l / I�� Seismic
e L or Cotle,far the pertormence of the work for which Ihle permit is Issued.My Worker's 1
Compensation Insurance terrier antl Policy number ere: �y♦�� I' � - Tote
carrierRDK71 POIicyNo."ZU�UV (2s`> _ PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'.
COMPENSATION INSURANCE N.C.p
'(Ths section need not be completed If the peimit Is for one hundred dollem($100)or lass.),
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 Cell- - All roof^shall be inspected priocto any roofing material being
farms. installed. If a roof is installed without first obtaining an
_ Date Applicant - inspection;I agree to remove all new materials for inspection.
subect toBthee Worrkers'Compensate provisions ofethteflLaborr Code,yolu nm.yso
ust bnhwithbcomply APPIICanS Understands and will Comply with all non point
.with such provisions or this permit shaNbe doomed revoked.. Source regulations.
I certify that I have read this application and state that the above Information Is carrecl.l a s�''��
to comply With all city and county ordinances and state laws relating to building constructio antl A I verin lass"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned proper or In. 1 Zo O v
apedZ
ion purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertinoagainst lie tae
judgments,costa and expenses which may In any way accrue against said CIN In conee9 IC
of the granting of this permit. SI OF 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. .