R 4941 PERMIT 4 9 41
APPLICATION FOR CITY of cuPERTINO NUMBER R'
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
10'f03 NOEL AVE. RESIOENTIAL_ZS—COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand tilat a Class A
NAMEPARVIZ 4 KATHY KHOOI roof assembly is required.
NO - Initialle LC.B.O.N
ADDRESS/0H03 NOEL AVE. I EXISTING ROOF COVERING
PHONE �/O8 865- 1'YZ3 NUMBER OF EXISTING COVERINGS t
CONTRACTOR'S
NAME PH i L L t P SAAICH E Z TO BE REMOVED I TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
CITY&zlP/N7/ AMEsa RY WAY
EXISTING
PHONE BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
hereby affirm that I em licensed under Professions
of Chapter 9(commencing with Section WOOD SHAKES
]000)of Division 3 of the Business and Prolesslons Code,and my license is in full torte and
effect.
License Class C-�3'1 1Number
y&D79a WOOD SHINGLES El
Date_(QA919e0 Contractor Pf1/G1-/00 SRVCHK?_ OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's U as Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city o my which requires a permit to
construct.alter,Improve,demolish,or repair any structure,pri its issuance,also requires the BUILT-UP ROOF El
for such permit to file a signed statement that hetisl ce tl.pursuant to the previsions
of the ss and
License Law(Chaplet h(com=mpt with 3e 000)basis
Division 3 le the
• ex
Business and Professions Code)or that he Is V applt t rel rtl basis forhe the alleges ASPHALT SHINGLES
exemption.penalty of violation more
than
hun r by y eppllca mit subjects the applicant to
e civil penalty of not more then five huntlrefollem($5 0
❑I,as owner of the property,or my amyl is as a as their sole compensation,will do WOOD SHAKES
the work,and the structure Is not trite do r off p or sale(Sec.7044,Business and Profen
sions Coda:The Contractor's Llcensbiaw as n apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does suchJ`vo Il or through his own employees,provided that ❑
such Improvements are not Intended'ottyy aredr sale.If,however,the building or improvement
Is sold within one year of completion,thebwnanbullder will have the burden of proving that he did OTHER(SPECIFY) 1:1not 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 Guilds or improves thereon,and who contracts for such projects
with a contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under sec. ,B&P.C,for this reason
owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: ��
❑ have and will mainteln a of thel Lab of Consent to Performa for Worker's Compensation, rBUl dm
asprovided issued.
dfor by Section 3700 of the Labor Code,for the performance of the work for which this V g
permit Is ve and 1991), Seismic
have end will maintain Workers Compensation Insurance,as requireditsIssued.
Section Worker'.
of CC Y 9
the Labor tion I ur the performance of the work r a which this permit is Issued.My Worker's N 1 �t
Compensation Insurance carrier end Policy number era: � Total
CarrlerSTRrE FUWD Policy No,/3/OG5'S-9d PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
.
COMPENSATIONif theINSURANCE NC[] /1
(This section need not performance completed it the permit is for one hundred sued,I(5100)or less.) IA—
certify thatn theneersosto of the work for which this permit is Issues shell not employ
any person in any manner so as to become subject to the Workers'Compensation Laws of Cali. All roofs shall be inspected prior to any roofing material being
fornla, installed. If a roof is installed without first obtaining an
Date tJ8/96 Applicant �i � inspection,I agree to remove all new materials for inspection.
Non TO APPLICANT: If,after making this Certiffitlate of Exemption,you sg a become Applicant understands will I with all point
subject to the Workers'Compensation provisions of the Labor Code,you must to twith comply PP s ancomply Y non
with such provisions or this permit shad.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 be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities, 6
judgments,costs and expenses which may In any way accrue against said City in consequence
• o1 the granting of this permit. SIGNATURE OF APPLIC ATE
PRE-INSPECTION: PLYWOOD: IN-PROG SS:
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 COPV