R 5172 PERMIT R_ 517 2
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNE 'S HAZARDOUS FIRE AREA
I understand
i
��&i�- K6 AICi/�/SL SOti YES ❑ IIyes— lyi and thtat. Class
NAME roofs— srequired.
NO Initial I.C.B.O.q
ADDRESS S 9 �— EXISTING ROOF COVERING
PHONE
NUMBER OF EXISTING COVERINGS 'SffiA-K-E_
CONTRAC/TO�R, TO'S /� /
NAME 1- S [�'_/YT6a BE REMOVED r TO BE RETAINED
ADDRESS p c'9 TYPE OF ROOF COVERING -
CITY&ZIP " '� �Of /-7 G L!/S �S 9SnS/
EXISTING
PHONE 3 5-8 Z 3 3 BUILT-UP ROOFLICENSE
❑
NUMBER IF 573 y- G ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full tome and
ellen' WOOD SHINGLES ❑
License Cleve up,Number`;
Date 9' �/ Contractor �� OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
hereby affirm Bu that am exempt from the e:Contractor'scity License Lew for the following permit
t.
(Sec.construct.
It Business and demolish,
or re Code: Any city or county which requlrea a permit to
construct,alter,Improve,to file signed statement that
prior tope issuance,also requires the BUILT-UP ROOF ❑
applicant for each permit to Ills a signed statement Ihel he ithlicensedSectio pursuant to the provisions the
of the Contractor's License Lew(Chapter 8 Is axe ncln with Section 7000)of Division 3 0l the
Business and violation of Code)or thet he le exempt a tfora and the seals for the ailette ASPHALT SHINGLES 591
exemption.Anyviolationora moos Section 7031r byany eppllcentfora permit subjects the applicant to
e civil penalty of not more than rive hundred dollars($500).):
❑I,as owner of the property,of my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for Sale(Sec.7044,Business and Prolee-
elone Coda: The Contractor's License Law does not apply to an owner of property who build$or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,provided that ❑
such Improvements are not Intended or offered for sale.If.however,the building or Improvement
Is sold within one your of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,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 dose 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 a contestants)licensed pursuant to the Contractor's License Law, PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sac. ,B It P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby a81rm under penalty of perjury one of the following declaration: �'
❑1 have and will maintain a Certificate of Consent to self-insure for WorkeCompensation, BUlldi4
as provided for by Section 3700 of the Labor Cotle,for the performance of the work for which this
permit is Issued. Seismic C]I have and will maintain Workers Compensation Insurance,as required by Section 3700 of c /Q Q
the Labor Code,for the performance of the work for which this permit Is Issued.My Workefe SEP 171996 Total
Compensation Insurance carrier and Policy number are:
Carrier G/9C efo_ rrr/ Policy No.4�F40/7;xS PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.]
(This section need not be completed If the permit is for one hundred dollars IS700)or less.) -
s I certify that In the performance of the work for which this permit is Issued,I shall not employ
any person In any manner e0 as to become subject to the Workers'Compensation Laws of calk All roofs shall be inspected prior to any roe ng material being
fertile. installed. If a roof is installed without first obtaining an
Date�—y 7-rc Applicant inspection,I agree to remove all new materials for inspection.
- NOTICE TO APPLICANT: II,seer maklnB this Certlllcaro of Exemption,you should become A Ilcant understands and will cora
' aublect fo the Workers'COmpeneatlon proviclone of the Labor Cotle,you must forthwith wmply PP ply with all non point
yvlih such provlelone or this permit shell ba deemed ravokatl. SODTCe reg DlatlOn S.. -
1r•. certlty that have featl Ihl$applicallon and$tete that the above Informetlon IS correct. agree
I• o complywllhellciryend ceunry ortllnancesentl stele laws relatlnpto bullctng conslruplon,antl Ali roof coverings to be class"C"or better.
hereby authorize repreeentallvea of IMS city t0 enter upon the above-mentioned property for In-
epectlon purpaeee.
(We)epee to save,Intlamnity end keep hermleas the Clry of Cupartlno against Ilabllitles, ��,� /� /" �-/J-5:',C
jutlpmente,caste end expenses which may In any way accrue egelnn sem Clry Inconsequence $IATURE OF APP[ICA� DATE
of the granting of thio permit
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
(NSP. 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