R 39620
M .
MI
R- 3962
APPLICATION FOR CITY of CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
PERMIT
EXPIRES IF WORK IS NOT STARTED
(408)252-4505 EXT. 228 WITHIN IN DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
I
_ BUILDING USE
/�/J/J
222-173 '
6
+4
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS )))) 1 ROOF
NAME
FIRE COVERING
AREA CLASS
EXISTING ROOF COVERING
ADDRESS.-
NUMBER OF EXISTING COVERINGS
PHONE
CONTRACTOR'S
TO BE REMOVED_ TO BE RETAINED
NAME rr—A
TYPE OF ROOF COVERING
./.,s
(Q -b_
ADDRESS/
0-0. S
ITY & Z16 Q - `
EXISTING
BUILT-UP ROOF
S
PHONE
ASPHALT SHINGLES
/
LICENSE
NUMBER
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I with S ction met 1 of licensed 3 of T Provisions of dChapterProle s (common
Ting Section 70001 0l Division or Ina Beainesa .m P.ofesel ns cos.,
WOOD SHINGLES
y [I
and my Class fu0 (Pica ane e11«c J/� q(
Demo Class 'SS7 Number i b.l W
OTHER (SPECIFY)
Deb Contractor
Con
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Lew tar
the following reason. (S«. 7071.8, Business and Professions Code: Any city
PROPOSED
or county which requires • permit to construct, sitar, improve, Cemolish,or
repair any structure, prior to Its Issuance, also requires the applicant for such
Palm to Ii lee signed statement that he Is licensed pursuant to the provisions
BUILT-UP ROOF G/
of the Contractor's License Lew MIT motor g it ommsnc i ng wi Th Sec tion 7000)
of Division 7 of the Business and Professions Code) or that he is exempt there'
from end the basis for the alleged exemption. Any violation of Section
ASPHALT SHINGLES
7071.a by any applicant for a Permit subjects the applicant to a civil penalty
of not more that five hundred dollars Issom.):
WOOD SHAKES x
C I, as owner of the Property, or my amploven with wages as their sob
compensation, will do the work, and the structure is not intended or offered
for ole (Sec. 7044, Business and Professions Code: The Contractor's License
WOOD SHINGLES
Lew do" not apply to an owner of property no build. or improves thereon,
and who eon such work himself or through his own employees, provided that
such improvements are not intended or offered for tele. If, however, the
OTHER (SPECIFY)
building or improvement is sole within one year of completion, the owner
builder will have the burden of proving that he did not build or improve for
ppr0 1 of sale.).
I, as owner of the property, with licensee
PROVIDE I.C.B.O. REPORT NO.
t (exclusively Businsscontracting
to construct the project (Sac. t app Business nen end Profession
code: The
Coact:builds Tits ofpropertyWith
and doewho
PROVIDE MFGR. INSTALLATION SPECS.
hicenee cot tracts foeuch pr
who of improves
improves end who contracts for such projects wins a
nt
ontract
actorO l su to
licensed pursuant to the Contractor's License Law.
am
r...on I em exempt antler Sac. ,B.d P.C. for to is
APPLICATION DATE
VALUATION
PERMIT FEE
owner Data
WORKERS' COMPENSATION DECLARATION
Building',
I hereby affirm that I have a certificate of consent to selldneure, or a car
tificm of Workers' Compensation Insurance, or a certified copy thereof (Sec.
7800, Lab. C.1.
J�
/ !�—
Seismic
Policy Na. Company
/Vl_ �!S_e G t
�/ t .`
GX./
ji
Certified copy is hereby furnished. n
8 Certified ropy is filed with Il city inspection division.
J/.
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//
Total
Applicant
CERTIFICATE OFSATION EXEMPTION
N `, ❑
PERMI
HORIZATION
DATE
ROM WORKERS'
COMPE.(This section
not be cumpteutl it is for
r LVrC
the permit one hundred tlob
bre ($ero) or Ins.)
.)
/1
ryflNV (v
I cantly toot in me performance person
of the work for which this a subject b
any prison n any manner e-0 n to become subjact
louse, I shell not employCompensation
IO
to the Workers' Compemetion Laws of California.
Deb AT:
NOTICE APPLICANT: If, after making of Exn. pilon,
should om nsatiicab
youshould b subject o the Compensation of the
coma
w'
i ns or tom
Labor Ootla, ed r must forthwith comply with such provisions or this permit
comply
shall be aeam.e ravgk.a.
All roofs shall be ins petted prior to any roofing materiel being
I certify that I have road this application dna sten that the above informs
installed If a roof is Installed without first obtaining an
tion Is correct. I ogres to comply with .B city and county ordinances and
Dote laws relating to building construction, and hereby authorize represen.
inspection, I a to remove all new materl8lafOr
actri tree
p g Inspection
tetives of this city to enter upon the above-mentioned Property for Inspection
Purpose.
IWO) agree to save, indemnify and keep harmless the City of Cupertino
against liabilities, Judgment., cost. and ..pan.. Which may In any way «cru.
SIGITATURE OF APPLICANT DATE
against Said City in consequence of me 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 FOR INSPECTION
OFFICE COPY