R 4997U
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PERMIT
'4997
R_.
APPLICATION FOR CITY OF CUPERTINO :: NUMBER
INSPECTION DIVISION - PERMIT EXPIRATION
REROOF PERMIT (408)777-3228.' - PERMIT EXPIRES IF WORK IS NOT STARTED
I' WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
-BUILDING ADORE SS
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RESIDENTIAL- COMMERCIAL OTHER
OWNER'S - _
HAZARDOUS FIRE AREA
YES B Class A
U9�, C e
❑ yes —1 understand that a
NAME /Y ` ��✓ / !%tp
roof assemdy is required.
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- EXISTING ROOF COVERING
'ADDRESS ..S�6hi
`NUMBER
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PHONE C/D9� �,,�9r y�yy '
OF EXISTING COVERINGS
TO BE REMOVED '� TO BE RETAINED
CONTRACTOR'S"�// ,��%J' p L/.
NAME /flezu e_ 14 J /�I&
ADDRESSf�QrQ~�
TYPE OF ROOF COVERINGEXISTING -
arY a zIP 4�,1 /s
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PHONE ' "
❑
BUILT-UP ROOFLICENSE
NUMBER SG%Syi
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
hereby affirm that I am licensed under provisions of Chapter a (commencing with Section
WOOD SHAKES
7000) of Division 3 of the Business and Professions Code, and my license Is In lull force and
effect `
�
WOOD SHINGLES' ❑
t License Cle�ae —0 Uo. Number
97 y�'w Oo�%:�
OTHER (SPECIFY) ❑
Date% contractor
OWNER -BUILDER DECLARATICKPROPOSED
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 Issue e, also requires the
applicant for such permit to file a signed statement that he is licensed puns tithe provisions
BUILT-UP ROOF - ❑ "
o the Contractor's License Law (Chapter 9 (commencing with ctlon7 ) of DNttslon 3 of the
Business and Professions Code) or that he Is exempt therefr .and in setsJaF the alleged
,
ASPHALT.SHINGLES
exemption. Any violation of Section 7031.5 by any spell I4or perm b cis eappllcantto
a civil penalty of not more than five hundred dollar );
.p1, as owner of the properly, or my employe mwe s el ys ompensellon, will tlo
WOOD SHAKES ❑
the work, and the structure Is not Intended or .11
e 8C,"d4, Business and Proles -
sone Cotle: The Contractor's Cleanse L doe
ply to up. owner of property who builds or
Improves thereon, and who does cuch worWM e r inroyygqKh his own employees, provided that
WOOD SHINGLES ❑ ,
such Improvements are not Intentletl or offered for Iqq,�H,'howevea the building or Improvement
issoldwlthinoneyearofcompletlon,theowrlenbull fWill have the burden ofproving that hedid
-
OTHER (SPECIFY) ❑ "
not build or Improve for purpose of sale.).
❑ I, 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 LC.B.O. REPORT NO.
apply to an owner of property who builds or Improves thereon, and who contracts for such projects
with a contractor([) licensed pursuant to the Contractor's License Law,
PROVIDE MFGR. INSTALLATION SPECS.
❑ 1 am 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 declaration:
r -1I have and will maintain a Cehificate of Consent to self -insure for Workers Compensation,
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BUlldln '3+ e0
g
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
permit is Issued.
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Seismic .90
❑1have and will maintain Workers Compensation Insurance, as required by Section 3700 of
-
-the Labor Code, for the performance of the work for which this permit Is Issued. My Workers
s
Total, 7 9
Compensation Insurance carrier and Policy number are:
s�4fe �Ad �y.1030,0
PERMIT AUTHORIZATION
DATE
Carrier Policy No.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
n
(This section need not be completed If the permit is for one hundred dollars ($100) or lass.)
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2W7?
1 certify that In the performance of the work for which this permit Is issued, I shall not employ
All roofs shall be inspected prior to any roofing material being
any person in any manner so as to become subject t the Workers' Compencatlon Laws of Call.
torula.
installed. If a roof is installed without first obtaining an
Date Applies ��
inspection, I agree to remove all new materials for inspection.
Applicant understands and will'comply with all non point
. NOTICE subject to the Workeris' Compefneatlorn pparovslonethis
olu mustuforthwlllhbecome
of theflLaborr Code, Exemption,
comply
with such provisions or this permit shaKe deemed revoked.. -
Source regulations.
I certify that l have read this application and state that the above Information Is correct.I agree
to comply with all city and county ordinances and erste laws relating to building construction, and
All roof coverings to be class "C" or better.
hereby authorizerepresentatives of this city to enter upon the above-mentioned property for In.
-
- spection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino apelnet liabilities,
judgments, costs and expenses which may In shy way adUlig AgglB9t Said city n consequence
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SIGNATURE OF APPLICANT - 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. ACCESS TO ROOF SHALL BE PROVIDED FORINSPECTION
OFFICE COPY