R 5166 PERMIT R_
APPLICATION FOR
CITY OF CUPERTINO NUMBER 516 6
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (4178)777-3226 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
. 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS // /�/Y
'//( O /'� -(/VIGCJ RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes-I understand that a Class A
NAME •I � root assembly is required.
Cc NO ❑ Initial I.C.B4O.B
a ADDRESS V EXISTING ROOF COVERING
C
k PHONE '� V 3 — V NUMBER OF EXISTING COVERINGS 1
CONTRACT;
TO BE REMOVED / TO BE RETAINED
NAME C/
AODREssif 0 SS TYPE OF ROOF COVERING
CITYazip7 � EXISTING
/� QL
5 3
PHONI%: / _S `7 7 O —O3 G Z BUILT-UP ROOF
LICENSE !
NUMBER !� // 7 ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 0(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 sSu�sS pD�
License Class Llc,Number 1 r I V
(�J _ OTHER(SPECIFY) OCT 4 1996
❑
Data Contractor
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from the Contractor's License Law for the M owing reason.
(Sec.7031.5.Business and Professions Code: Any city or county which requ res a permit to CI I Y Ur WJr Crl l IIYV
construct.alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF Ll
applicant far such permit to file a signed Statement that he Is licensed pursuant to the provisions
of the Contractors License Law(Chapter a(commencing with Section 7000)of Division 3 of the ❑
. Business and Professions Code)or that he Is exempt therefrom 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($500).):
❑ WOOD SHAKES as owner of the properly,or my employees with wages as their sole compensation,will do ❑ AfoL W� as
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profes. w
slons Code:The Contractor's License Lew does not apply to an owner of property who builds or WOOD SHINGLES
improves thereon,and who does such work himself or through his own employees,provided that ❑ ,/$r
such improvements are not Intended or offered for sale.If,however,the building or Improvement /r Gh
is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) Q iJJ
not build or Improve for purpose of sale.).
❑I,as owner of the properly,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Law doe.not PROVIDE I.C.B.O.REPORT NO.
apply to an owner or property who builds or improves thereon,and who contracts for such projects
with a contmctor(s)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR. INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: O /
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, 6
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this �� Building
pe�rm}�is issued. Seismic
have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
the L bar Coda,for the performance of the work for which this permit is Issued,My Worker's q
Compensatl Ie`ceOrrIs e d Policy numb[§�hera: L Total
07 Carrier ` ��lz / •Q]�R� Policy No. k- P-141 U v
PERMIT AUTHORIZATION DATE
CERTIFICATE EXEMPTION FROM WORKERS'
r
COMPENSATION INSURANCE N.C.I]
s (This section need not be completed if the permit Is for one hundred dollars($100)or lose.)
I 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 Worksm'Compensation Laws of Call. All roofs shall be inspected prior to any roofing material being
ferns.. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
�eoeyeCOoeaimaking efluubecome
subthW rrampne ce provisions ofthe Laborr Code,you mstforthwlhcomply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. Source regulations.
1 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 Ove to be cL2ss"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in. / /
ep(We) purposes. t /V/ 7/
(We)agree to save,indemnify and keep harmless the City o Cupertino against liabilities,
at the gran costs and expenses which may In any way accrue against said City In consequence
. of me granting of this permit. SIG ATUBE OF APPLICANT bAT� --
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