R-4678 PERMIT R_ 4 6 7 8
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
BUILDING ADDRESS
1 B DAYS FROM LAST CALLED INSPECTION.
1 \/
RESIDENTIAL_L_COMMERCIAL OTHER
OWNER'S ^1 HAZARDOUS FIRE AREA
" III— tZI,Z�� YES ❑ If yes—I understand that a Class A
NAME roof assembly is required.
}� NO InWal I.C.B.O.R
ADDRESS loz�t�: ` uL "� EXISTING ROOF COVERING
PHONE J 1 �Z—ZS NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
-Z 'c r-- �G TO BE REMOVED___L_TO BE RETAINED
NAME
ADDRESS p�( �y Slq'r''�� t� TYPE OF ROOF COVERING
CITY&ZIP c C LIAR
TING
PHONE
PHGNE 1 1 BUILT-UP ROOF ❑
NIUMBER 3coco5'�� - ASPHALT SHINGLES El
CENSE
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license is In lull force and
effect. ,
l^ S_ WOOD SHINGLES ,,
El
License Class `� Lmc.Number - . . :
Dale
\- Contractor 21 �1 S�ZtiZ—C -0THER(SPECIFY) �" r.`' ❑
pyoOWNER-BUILDER DECLARATION PROPOSED A l/ 97
1 hereby affirm that i am exempt from the Contractor's License Lew for the requires
a reason. 1995
(Sea 7ct, It ,improve,
and Pres,or rep Code: Any dry or county which requires a permit to Gl)v . OJ
construct,alter,Improve,to file siorrepeatemystructure,prior to Its Issuance,also requires the BUILT-UP ROOFT (� ❑
applicant ler such permit to Ills a signed statement that g with
Section
pursuant to the provisions
• of the ss and Contractor's License Law(Chapter B(commencing with om and 70001 of Division 3 of the CyTI//�,U
Business and violation of Code)or that he Is exempt therefrom and the sbasisubjects
for the alleged ASPHALT SHINGLES
exemption.Any f not ion of than
7031.5 by any applicant for a permit eubjecte the applicant to
e civil penalty of not more than live hundred dollaemployees
with
wag.): WOOD SHAKES ❑
❑Les owner ofthe propertyor tmy eemployeeswith wapae astheir sole compensation,will s.
the work,and he Cont
tacto Is not intended or offered for sale(Sec.7064,Business and Proles-
imorovesth TheContractor'oessuchworkhim not apply to an rthroughhiso or own
ployeerywho rovidebuilds or WOOD SHINGLES
improves thereon,and who does such work himself or through his own employees,provided that ❑
such d within
one year
are not completion,
leb n,th altered fpr sale, ill however,the hulloing or iImprovement ---��°0°--QQ7Q7//, L 7V W 41:1),
Is not bull or
prove for purpose of
owner-builder will have the burden of proving that he did OTHER(SPECIFY)
not build as
Improve ler purpose of sexclu
❑I,as owner of the property,em exclusively contracting with Incensed.License
I-to construct
the project(Sac.7066,Business and Professions Code:The Contract ors License Lewdoes not PROVIDE LC.B.O.REPORT NO.
apply to an owner of property who builds or Improves(hereon,and who contracts for such pretecta
with a contractors)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 em exempt under Sec. ,S 6 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PER IT EE
WORKER'S COMPENSATION DECIARATION
I hereby affirm under penalty of perjury one of the following declaration: 1
❑I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, ^�` Buildin
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this W
permit is issued. 11 'Z l �4'� Seismic
,Zfhave and will maintain Worker's Compensation Insurance,as required by Section 3700 of
Ko LaMr Code,for the performance of the work for which this permit Is issued.My Worker's Total
Compensation Insurance carrier and Policy�mber are:
CarrierST��� IF
Policy No. � �\ PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O `
(This section need not be completed If the pqfN Is for one hundred dollars($100)or less.)
1 cedity that In the performance of the work 1 r w ch this permit saved, shell n t employ
any person n any annet eo ge to become sub ct t the Worker' o pM9eUon La pl can- All roofs shall be inspected prior to any roo ing material being
joints. ^ )/ installed. If a roof is installed without first obtaining an
Date '\ i`�� Applicant inspection,I agree to remove all new materials for inspection.
NOTsubject I.theCE OWorrkeres'Compensation proafter ivisionis oftheicate Of Laborr Code,y tum you
foinwiih molt' APP(' nt understands and will comply with all non point
with such pr0vismons or this permit shall be deemed revoked. SOU a egulation -
I certify that I have read this application and state that the above Information Is correctI agree
to comply with all city and county ordinances and state laws relating to building construction,and All
OfC VefingS "Of be
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes. '� \ -2� q
(We)agree to save.Indemnify and keep harmless the City of Cupertino against liabilities,
• judgments,costa and expenses which may In any way accrue against said City In consequence 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY