R 5852J
OFFICE COPY
PERMIT R_ 585 2
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
- WITHIN 180 DAYS OF PERMIT ISSUANCE OR
160 DAYS FROM LAST CALLED INSPECTION.
ADDRESS
BUILDING"ADDRESS.—/
RESIDENTIAL COMMERCIAL OTHER
HAZARDOUS FIRE AREA
VES ❑ If yes — I untlerstand ttlat a Class A
t
f
NO _ roof assembly is requiredIniiisl��_ I.C.B.O. k
�*O J
PW
EXISTING ROOF COVERING
c GIed 6,� /J A.1(
(�ESgg
PHOfJE
NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
t
L /
TO BE REMOVED TO BE RETAINED
NAMErCIto c
ADDRESSTYA
3637 S.Veye
OF ROOF COM
CITU 8 ZIP
EXISTING
❑. / K�p�
BUILT-UP ROOFLICENSE
7
PHONE 2Z 1 5- � D �
NUMBER l� 3 2 S_
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter S (commencing with Section
WOOD SHAKES
7000) of Division 3 of the Business and Professions Cotle, and my license is In full force and
effect.
t.
C. %! it 3 Z
WOOD SHINGLES ❑
License Cleao Lic. Number -
'�&iad!0 Ifo --99! S14e e'o iJq//V eo(�'
Data �_
OTHER (SPECIFY) ❑
-extractor
OWNER -BUILDER DECLARATION
hereby that I am exempt from the License Lew for the followingreason.
PROPOSED
(Sec. 70315, , Bu e: Any city
and Professions Code: Any city or county which requlrae a permit to
requires
, Improve
construct,alter,Improve, demolish, structure, prior to Its Issuance, also requires the
BUILT-UP ROOF ❑
to file n dpursuant
applicant for such permit a flaw a signed r9(co statement that he IB licensedactio pursuant of
the provisions the
of the Contractor's License Law) (Chapter (commencing with Section 7000) of 3 of the
Business Professionslotionof
and h
Code) or that he is exempt therefrom and the beefs for the alleged
for the
ASPHALT SHINGLES ❑
exemption. Anyf violation al Section 7031,5 by any applicant for a permit subjects the applicant to
civilpe more (h wag ):
e civil penalty of not mere thanpert floe hundred employees
❑Irks er property, or my oyeeered wages as compensation,sndPrlll
WOOD SHAKES
and c.70heir
the work, antl the structure ie not Intended or offered for eels
the structure is tended s.
4. Business and o-
n owner of builds
License work him not applyor
property who Provided that
Improsions Code: The Con who
Improves thereon, and who does deco work himself or through
through e own employees, etl that
WOOD SHINGLES
such Improvements are not offered for Belo. however, the
e o
or Improvement
Improvement
e r of completion,
leb n, the ill en of pr i
sold withintbuildorI
OTHER (SPECIFY)
provne
n forpurposetofstheowner-bulltlarwillhavethebuMenofprovingloathedid
not build or Improve for purpose of sale.).
❑
❑ 1, 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 I.C.B.O. REPORT NO.
apply to an owner of property who builds or improves thereon, and who contracts for such projects
with acontexempt licensed pursuant to the Contractor's License Law,
❑ I em exempt under Sec. ,B 8 P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner
WORKER'S COMPENSATION DECLARATIOATION
•APPLICATI N'0ATEJ ATE
VALUATION
PER FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑ 1 have Certificate
/1 j�
�5i�
and will maintain a of Consent to sell -Insure for Worker's Compensation,
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
A$fAs
BUlldln
permit Is issued.
C11 f
,❑ I have and will maintain Worker's Compensation Insurance, as required by Section 3700 of
the Labor Code, for the for
V7-
vVi lI(/ll
Seismic
performance of the work which this permit Is Issued. My Worker's
Compensation Insurance carrier and Policy number are:
y(•
Total
Carrier Policy No.
PERMITAUTHORI TION
DA
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C .❑
C)
(This section need not be completed the permit Is for one hundred tlollara ($N or IesoJ
\V�
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 kofing material being
any person in any manner so as to became subject to the Workers' Compensation Laws of Call.
forms,
installed. If a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It, after making this Certificate of Exemption, you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
Applicant understands and will comply with all non point
pp p y p
with such provisions or this permit shell be deemed revoked.
Source regulations.
I certify that I have read this application and state that the above Information II correct. I agree
to comply with all city and county ordinances and elate laws relating to building construction,end
Al coverings to be lass o better.
hereby authorize representatives of this city to enter upon me above-mentloned property for In-
sp(We) purposes.
(We) agree to neve, Indemnify and keep hermleea the City of Cupertino against liabilities,
/� _
ludgmorte, costo antl expenses which may In any way accrue against said City In consequence
of the graining of finis Perms.
ATU E OF APPLICANT DAT
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