R-5699 PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 5699
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 /
'i/ J Io RESIDENTIAL ✓ COMMERCIAL OTHER
OWNER'S - - - HAZARDOUS FIRE AREA
infer
1 /w/1 t �/�I^� VES ❑ If yes—I understand that a Class A
NAME ��ry1. Y��K�].. „ rt r assembly is required.
1 NO Initial I.C.B.O.#
ADDRESS -'0 qD Op C��y S l-y EXISTING ROOF COVERING
PHONE 2, s? — 0691 - NUMBER OF EXISTING COVERINGS Ogle
CONTRACTORS
yeCONTRACTOR'S / pp, //^^
Cott v1 e4 II r_ (1 0O/;L( TO BE REMOVED SN G TO BE RETAINED C��P
NAME \7
ADDRESS �/ S �ov7T0 j(qr-ry G7; SrQ.N fo,S G4 TYPE OF ROOF COVERING
CITY IL ZIP v
(/ l �y �tD EXISTING ,
PHONE` ���/ � R7— �7a8 BUILT-UP ROOF ❑
LICENSE
NUMBER Z O If ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION '
hereby affirm that 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.
9 / OD SHINGLES ❑
License Class C—3 ` Lic.Number `�
Date
7- Contractor
9- 57 CoR#1"S40gC, ("D ,- < OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED /
hereby affirm that am exempt from the Contractor's License Lew for the fallowing reason. L /`�
cons.7031.5,alter,improve and Professions Code: Any city or county which requires a permit to ! �//"
conscnt,orsuch permitve,todemolish.filigned air statement
eny mentructure,that he prior Jolts issuance.also to the
BUILT- ❑
applicant for such permit to fila a signed statement that he Is licensed pursuant tit me pro of the
of the Contractor's License Law(Chapter a(commencing with Section]OOO)of Division 3 of the
• Business and Professions Code)or that he Is exempt therefrom and the basis for the elle ASPHALT SHINGLES
exemption.Any violation o1 Section 7031.5 by any applicant for a permit subjects the app' to
e civil penalty of not more than five hundred dollars($501
❑I,as owner of the property,or my employees with wages as their safe compensation,will do
the work,and the structure is not Intended or Offered for sale(Sec.7004,Business and Profes-
sions Code:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES �
improves thereon,and who does such work himself or through his own employees,provided that L
such Improvements are not Intended or offered for sale.If,however,the building or improvement
Is sold within one year of completion,the owner.builder will neve the burden of proving that he did OTHER(SPECIFY)
not b or Improve for purpose of sale.).
❑1,I,as ec owner of the property,and Professions Code:
T e C licensed contractors to construct
the prolan(Sec.7004,Business end Professions Cotle:The Contractor's Licosa Lew prof not PROVIDE LC.B.O.REPORT
apply to an owner of property whobuildst or Improves thereon,and who contracts for such projects
with a eontexem t licensedrSe pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLW I ICIN'9F'tti 1 iNU
❑I em exempt under Sec. is 8 P.C.for this reason
Owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to sell-Insure for Workers Compensation, ^ Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
/
permit is Issued. (0�// //(,�{j,,/, Seismic U
labor and wool maithe performance
Woance Compensation the woror Insurance,as permit
dsu Section Worker's's 9
the Labor Code,for inn pedormen of of the work far which this permit Is laeuetl.My Worker's /
.the
Insurance terrier antl Policy number are: Total '
Carrier S1<48 �F'a, Policy Na,)yd1o83,)-`14, PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.O0
(This section need not be completetl If the Permit is for one hundred dollars($100)or lase.)
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'Compeneatlon Laws of Cali- All roofs all be inspected prior to any roofing material being
fornia, installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTsubject I.thCF e Workers'Compensation roivisionis ofthelcate of Laborr Code,Exemption
u must forihwitlh comply Applicant understands and will comply with all non point
v v v vv
with each provisions r ad his ap shalfbe doomed that the source regulations.
sato ppy that have and
thirty ordinances
state telttheabove Information Incorrect. agree
hereby authorize
rep entl county of this cls antl ter u on thearn to ve-me then construction,f and All roof coverings to be class"C"or better.
hereby epurp ze represanintives of info Illy to enter upon the above-mentioned property for In. ^ y;
apemen purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
judge gra'reg of andthis expenses which may In any way accrue agalnst said Cory In consequence SIGNATURE 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