R 4766•
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OFFICE COPY
PERMIT
R_ 476 6
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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
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIR, AREA
11
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YES ❑ If yeas I understand that. Class A
NAME_�1/�S . Sy S r"is l Z_
—/root assembly is required.
NO L� Initial I.C.B.O. q
^
;)—it � �l� woFi'�T ST'-
EXISTING ROOF COVERING
ADDRESS .ENCS
1
PHONE
NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME Iv
TO BE REMOVED TO BE RETAINED
ADDRESS hn 0 Mi -P Cn--
P'o' Pzrflk
TYPE OF ROOF COVERING
CITU 621P 3�J c7-3 �¢"eLV4 9�5�
EXISTING
%•%^ 0 33�
.
PHONE
BUILT-UP ROOF ❑
CENSE
NUMBER (-% 2c)2 $
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am Ilceneed under provisions of Chapter 8 (commencing with Section
WOOD SHAKES
7000) of Division 3 of the Business end Professions Code, and my license le in full tome and
effect' �r 6
Claes c_ a 7 Lie. Number ( `e-7 2_ 9 2-Q
WOOD SHINGLES ElLicense
^ Z ^`t G
OTHER (SPECIFY) ❑
oate I Contractora1Q. S itJw^�
OWNER -BUILDER DECLARATIO
I hereby allirm that I am exempt from the Contractor's License Law for the following reason.
PROPOSED
(Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to
construct,sitar.Improve,demolish, or repair any structure, prior to Its Issuance, also requires the
BUILT-UP ROOF Lj
eppllcant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractors License Law (Chapter a (commencin� with Section 7000) of Division 3 of the
Business and Professions Code) or that he Is exempt thorelrom and the basis for the alleged
ASPHALT SHINGLES
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).):
the
7
WOOD SHAKES ❑
01, as owner of property, or my employees with wages as their sole compensation, will do
the work, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Profes.
sions Code: The Contractors License Law does not apply toe nor of property who builds or
Improves (hereon, and who dose such work hlmaell or rough le own employees, provide0 that
such Improvements are not Intended or offeretl fo eel It, ho ever a ulltling or Improvement
issoldwithinoneyearofcomptetion,the own, wlllhe eth b enol provingthat hedid
WOOD SHINGLES ❑ G
/-
OTHER (SPECIFY) Sirk • MG-kS
not build or Improve for purpose of sale.).
❑I, as owner of the property, em exclusively nt cling wllhl a contractors to construct
the project (Sea 7044, Business and Profession Code: The Contractor's License Lew 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 contractor(e) licensed pursuant to the Contractor's License Lew.
1 am exempt under Sec. ,B a P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner oats
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION
PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
, �F7
❑ I have and will maintain a Certificate of Consent to eelHnaure for Worker's Compensation,
l
Building ti G
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
permit is Issued.
I] I have and will maintain Worker's Compensation Insurance, as required by Section 3700 of
Labor Code,
SEP16 199
-
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Seismic LLL
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the for the performance of the work for which this permit Is Issued. My Workers
Compensation Insurance carrier and number are:
I ,1 l
`J `Jr
Total
/Policy
k 1:;IVI") WC IyloS'�i�'ffilfo
PERMIT AUTHORIZATION
DATE
Carrier Policy No.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE INC.[]
(This section need not be completed if the permit Is for one hundred dollars ($100) or less.)
I certify that In the performance of the work for which this permit Is Issued, I shell not em toy
any parson In any manner so as to become subject to the Workers' Compensation Lowe of LP'
All roofs she a inspected prior o an roofing ateri I ing
fornix.
installed. If a roof is installs without first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If. alter making le Cq�tllicate of Exemption, you should become
subject to the Workers'C ompeneetion la na oglhe L or Code, forthwith
Applicant understands and will comply With all non
PP P Y
pr you moat comply
with such provisions or permit shell ams ravo a
I certify that I have reed Ihle epplicatl d et a the abwe Inlormellon la eaneq. spree
to comply ell clNand counryorolna cesantl eters la re101ing to building eonetrumlan,and
point
SOUTCB AgtlfBtTer4S.
A oof COVering9 t0 better.
with
hereby authorize representatives of this city to enter upon he above-mentioned property for In.
a or
spectton purposes.
(We) agree to save, Indemnity and keep harmless the City of Cupertino against liabilities,
a,
'
Jutl(We)
costa and expenses which may In any way accrue against said City Inconsequence
of the granting of this permit
SI URE OF AP ICA DATE
PRE -INSPECTION:
PLYWOOD:
IN -PRO SS:
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