R 4781 PERMIT R_ 4 7 81
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
•
WITHIN DAYS PERMIT ISSUANCE OR
WI DANSS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
C/V RESIDENTIAL COMMERCIAL OTHER
OWNER'S - HAZARDOUS FIRE AREA
VES ❑ I yes—1 understand that a Class A
NAME roof assembly is requiretl.
NO Initial I.C.B.O.N
ADDRESS C EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS ;6-4/el")
CONTRAC ^
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS '73d( /LC ! T /'`� TYPE OF ROOF COVERING
CITY&ZIP 'r ,S � 'c/ t EXISTING
Vo ?74.55
PHONE //' /J BUILT-UP ROOF El
LIUMBER em 3 !9 SO,5Io - ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter g(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is in full force and
affect /t r���� /1 WOOD SHINGLES El CI s Lie.Number `'�`� %—
Do Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby allirm that I am exempt from the Contractor's License Law for the to lowing reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requiroa a permit to
construct.after.improve,demoto file signed statement
he prior roils issuance,alsothe provisions
rone me BUILT-UP ROOF
applicant for such permit to Ilsei signed air any structure,
the Is licensed to Its pursuant thequire l the
• of the Contractor's License Law(Chapter g(comm g with Section 7000)of Division 3 of the
Business and Professions Coda)or that he is axe prefrom and the heels for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031,5 by any app) t or a permit subjects the applicant to
e civil penalty of not more than live hundred dol ra ,
C]1,as owner of the property,or my employee be as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or sale(Sec.7044,Business and Profes.
sions coda:The Contractors License Law a pply to an owner of property who builds or WOOD SHINGLES
improves thereon,and who does s It or through his own employees,provided that ❑
such Improvements are not Inten q for sale.If,however,the building or Improvement
Is sold within one year of completio , enbullder will have the burden of proving that no did OTHER (SPECIFY) ❑
not build or Improve for purposed
❑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 builds or improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
C]I am exempt under Sec. ,B&P.C.for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I affirm under penalty of perjury one of the following declaration:
!'7 ii1 u
Rveand will maintain a Certificate of Consent to self-Insure for Worker's Compensation, Building
as provide by Section 3700 of the Labor Cotle,far the performance of the work for which this
permltl aced. FEB 26 �99E Seismic
eve an
will mointaln Worker's Compensation Insurance,as required by Section 3700 of
iha abor Code,for the performance of the for which this permit Is Issued.My Workers
Camps Gr sure ecarriere Iicy er ere: l ,µe r/` Total
carrier V Pouc PERMIT AUTHORIZATION DATE
CERTIFICATE EMPnON FROM KERS'
CO If the r INSURANC C.
(This section need not be co etetl If the permit le for on unfired tl $ r lee
I certify that in the perfor n<)of the war k for which this ermit I u at
of
any person In y manner as to become aubJact to the rkere' omp II roofs 'nspected prior to any r ofing material being
fornia. in . If ar of is installed without first obtaining an
Data Applican action,I agr a to re ne lariats for inspection.
NOTI E TO AP IC NT: II,atter ma .1 ption, uld become Applicant Lind n • a i I
Subject the Wo ere'Campensetlon Prov he a rC e,you m orthwith comply PP y with all non point
with such provlot no or this permit shalgbe deemed revoked. Source regal S.
I certify that ave read this application and state that the above Information iscarrect.I e
to comply with at and county ordinances and state laws relating to building construct) ,antl All roof cov ' gs rbetter.
hereby authorize representatives of this city to enter upon the above-mentioned props for in.
spection purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino agal t liabilities,
judgments,costs and expenses which may In any way accrue against Bald Cityi consequence
at the granting of this permit.
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