R 5149 PERMIT R_ 5149
APPLICATION FOR CITY OFCUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
• WITHIN 100 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS ...�
l O O Y �Z—G C y,,J ZV C U Z� �� RESIDENTIAL COMMERCIAL OTHER
OWNERS HAZARDOUS FIRE AREA
^ /7 / . VES ❑ If yes—I understand that a Class A
NAME C 'l- Ll w roof assembly is required.
NO Initial I.C.B.O.q
ADDRESS ��JLL����G�� EXISTING ROOF COVERING
PHONE -744-- ! 1 y0 2- NUMBER OF EXISTING COVERINGS 2
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAME 7 /V� - 4>lill7
TYPE COVERING
cTY&ZP<,/ �LL as % 7 1Ertl-f? L7
EXISTING
PHONE lel 'Zv Li;A BUILT-UP ROOF
LICENSE
NUMBER ASPHALT SHINGLES Ell
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am Ilcensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Coda,and my license is In full force and
effect. ❑ �/
WOOD SHINGLES `
License Class LIC,Number
Date Contractor OTHER (SPECIFY) w�P i 7 t�
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,alter,Improve,demolish,or repair any structure,prior to its issuance.else requires the BUILT-UP ROOF � -
applicant for such permit to IIIe a signed statement that he Is licensed pursuant to the provisions
• of the Comractere License Lew(Chapter 9(commencing with Section 70001 of Division 3 0l the -
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES ❑
axemption.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 S500).): C 2 0
❑ S
I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES X766 1996
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profes-
sions Code:The Contractor'.License Law does not apply to an owner of properly who builds or WOOD SHINGLES I'
Improves thereon,and
who does such work himself or through his own employees,provided that I .t
^ v"� '• u'•.y
such Improvements are not Intended or offered for sale.If,however,the building or Improvement
Is sold within One year completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) of
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed Contractors to Construct
the select(Sec.7044,BueI " and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO.
ep oan owner of propertywho bulltla or improves thereon,and who contracts for such projects
withonhhulor(el licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑ e exempt or Sec ,B 8 P.C.for this rose
0
IV
Owner to — APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATI DECLARATIOI
I hereby afflr near penalty of perjury one of the lowing declaration:
❑I have and will maintain a Certificate of Consent o1sell-insure for Worker's Compensation, Vv
as provided for by Section 3700 o1 the Labor Cotla,forth performance of the work for which this Building J V
permit is have
anIssued. (��V Seismic
Q have entl will maithe pert Workers f the work
for Insurance,as required is i by Section Worker's 0l
_the Labor Code,for the performance of the work lar which this permit is issued.My Workers
Compensation Insurance carrier and Policy number are: Total -/ ,
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0 O
(This section need not be completed if the permit Is for one hundred dollars($100)or less.)
f 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'Compensation Laws 01 Cell- All fool's shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Dale Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP P y p
with such provi.lons or this permit shelgbe deemed revoked. SOl1fCe fag UI t' ns.
I certify that I have read this application and state that the above information Is correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,and roof coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes.
(We)
(Wel agree to save,' Indemnityand keep harmless the City of Cupertino against Ilobilltlee, Z A judgments,coats and expensespense,which may In any way accrue against saltl CityIn consequence SIGN
of the granting of this permit. U F APPLICANT DATE I
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
nFFIrF rnpv