R 5014 PERMIT R_ 5 014
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 JUL Z Z1996 - HAZARDOUS FIRE AREA
YES ❑ If yes-I understand that a Class A
NAME u _` f f roof assembly is required.
7p ^7 NO ❑ Initial I.C.B.O.0
�
ADDRESS / I 1 -7 Fr�T I VA(_ CT EXISTING ROOF COVERINGG r
PHONE V099 /
Z-�_7 - 7-3'? NUMBER OF EXISTING COVERINGS 1 6
CONTRACT R'S /n('�J
1
CT-t�Yl S�� — YA�� �' TO BE REMOVED TO BE RETAINED
NAME
�. ADDRESS TYPE OF ROOF COVERING
CITY&ZIP / J 05
r�p/1'r'r/"L CV�C�����
1 EXISTING
PHONE J ` d 1 -) 7d 03 6 Z BUILT-UP ROOF ❑
LICENSE O
NUMBER ( -7 ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed untler provislons of Chapter a(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license le In lull force and
enact. Q WOOD SHINGLES ❑
License Cleve ^ Uc.Number v
Dare 'Z Z Contractor 'K til - n t� OTHER(SPECIFY) ❑
OWNER-BUILD ECLARATION PROPOSED
I hereby affirm that I am exempt from the Cc r ctor's License Law for the following reason.
(Sec.7031.5,Business and Prof,saIona Code: city or county which requires a permit to
construct,alter,improve,demolish,or repair any air um,prior to Its Issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement o Is licensed pursuant to the provisions
of the Contractor's License Law(Chapter g((poPsmp Ith Section 7000)of Division 3 of the
. Business and Professions Code)or t t It is axe t • I( In and the basis for the alleged ASPHALT SHINGLES ❑
exemption.Any violation of Section 70 '8 yany Ica9I.for a permit subjects the applicant to
a civil penalty of not more than five hun tl of a
❑I,as owner of the property,or� e oy wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure I n .1 an (Ieretl for sale(Sec.7044,Business and Profes. '
alone Code:The Contra a tl e not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and e k f mealf or through his own employees,provided that ❑
such Improvements ere t a or of red for sale.If,however,the building or Improvement (�
Is sold within on "e yeeroto ,the wner-bullder will have the burden at proving that he did OTHER(SPECIFY) [+�pL✓t rota,y C
not build or Improve for' rR I eel .
❑I,es owner of the propert aml cluaively contracting with licensed contractors to construct
the project(Sec.7044,Busln a Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO. 206 3
apply to an owner of property, he lids or improves thereon,and who contracts for such projects
with a contractor a)licensed pur and to the Contractor's License Law.
❑1 am exempt under Sec. ,B 8 P.C.for this reason PROVIDE MFGR.INSTALLATION SPECS.
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
r ❑1 have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, �SG Q r
711?-/q UD BUllrfingl�a
/ I�
as provided for by Section 3700 0l the Labor Code,for the performance of the work for which this
permit is issued. Seismic
&rhavo and will maintain Worker's Compensation Insurance,as required by Section 3700 of
the Labor Code,for the performance of the work for which this permit Is Issued,My Worker's
(.
Counters he Inaurenca carrier and Policy number are: Total
Garner NA?711 NSC / ^ I/0 Policy N.4 2 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C. ] 1
(This section need not be completed If the permit Is for one hundred dollars($100)or less.) v
I certity 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 became subject to the Workers'Compensation Laws of Cali. All roofs shall be inspected prior to any roofing material being
fornia. 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: IL after making this Certificate of Exemption,you should became
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply Applicant understands and will comply with all non point
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 is correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof Coverings to lass"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes. 57
(We)agree to neve,indemnify and keep harmless the Clfy of Cupertino against liabilities,
lutlgmenta,casts and expenses which may In any way accrue against said Clty In comequence
of the granting of this permit. SIGN A E OF APPLICANT DATE
PRE-INSPECTION: PLYWOOD: AIN-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